2. INTRODUCTION
Typhoid fever, also known as enteric fever, is a potentially fatal
multisystemic illness caused primarily by Salmonella typhi
3. PATHOLOGY
S. typhi
- Gram-negative bacillus
Route of entry → Faeco oral (water and food)
Following ingestion of contaminated food
or water → the organism colonises the Peyer’s
patches in the terminal ileum → hyperplasia of
the lymphoid follicles → necrosis and ulceration
The microscopic picture shows erythrophagocytosis
with histiocytic proliferation.
4.
5. CLINICAL FEATURES
high temperature for 2–3 weeks
Continued
Step ladder pattern
toxic
abdominal distension from paralytic ileus
melaena due to haemorrhage from a typhoid ulcer; → hypovolaemia.
Perforation → peritonitis
Perforation of typhoid ulcer usually occurs during 3rd wks. And
is sometimes the first sign of the disease.
6. COMPLICATIONS
If the patient is left untreated or inadequately
treated, the ulcers may lead to perforation and
bleeding. The bowel may perforate at several sites.
Most common site of perforation terminal ileum the
large bowel can also be perforated
7. INVESTIGATIONS
Blood and stool cultures confirm the nature of the
infection and exclude malaria
The Widal test
The test looks for the presence of agglutinins
to O and H antigens of Salmonella typhi and
paratyphi in the patient’s serum.
8. Tubex to detect immunoglobulin M (IgM)
and TyphiDot to detect IgG and IgM.
These tests are particularly valuable
when blood cultures are negative
An erect chest X-ray or a lateral decubitus
film (in the very ill, as they usually are)
will show free gas in the peritoneal
cavity
9. TREATMENT
Resuscitation
Monitoring
Antibiotics
Metronidazole, cephalosporins and
gentamicin are used in combination.
Ceftriaxone.
Azythromycin.
Laparotomy is then carried out.
10. Choice of surgery depends on
general condition of the patient
the site of perforation
the number of perforations and
the degree of peritoneal soiling.
11. Mx of perforated site
closure of the perforation after freshening the
edges,
wedge resection of the ulcer area and closure,
resection of bowel with or without anastomosis
(exteriorisation),
closure of the perforation and side-to-side
ileotransverse anastomosis
ileostomy or colostomy where the perforated
bowel is exteriorised after refashioning the
edges.
12. NB
After closing an ileal perforation, the surgeon
should look for other sites of perforation or
necrotic patches in the small or large bowel that
might imminently perforate, and deal with them
appropriately.
Thorough peritoneal lavage is essential.
Closure
13. PROGNOSIS
When a typhoid perforation occurs within the first
week of illness, the prognosis is better than if it
occurs after the second or third week because,
in the early stages, the patient is less
nutritionally compromised and the body’s
defences are more robust.
Furthermore, the shorter the interval between
diagnosis and operation, the better is the
prognosis
