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  1. 1. TYPHOID Surgical Complications *DR. MANSOOR KHAN 28th Oct, 2009 * Resident Surgical “C”, KTH, Peshawar
  2. 2. TYPHOID Surgical Complications TYPHOID ical ati TYPHOID Surgical Complications TYPHO Sur Co TYPHOID Surgical Compli OID gical plications l ications T Surgi Complica PHOID urgical Complications TYPHOID Surgical Complications Salmonella a formidable killer! plica
  3. 3. “Potentially fatal, multi-systemic illness caused primarily by Salmonella typhi and paratyphi”
  4. 4. Typhoid---ancient Greek Typhos, smoke or cloud that was believed to cause disease or madness
  5. 5. S. typhi, a major human pathogen for thousands of years, thriving in conditions of poor sanitation, crowding, and social chaos
  6. 6. 430–426 B.C. Killed 1/3 of the population of Athens, including their leader Pericles. The power shifted from Athens to Sparta. 2006 study detected DNA sequences similar salmonella
  7. 7. Antonius Musa A Roman physician who achieved fame by treating the emperor Augustus with cold baths when he contracted typhoid
  8. 8. Thomas Willis (1621-1675) The first description of epidemic Typhoid in 1659
  9. 9. Carl Joseph Eberth (1835-1926) Discoverer of the typhoid bacillus in 1880
  10. 10. Georges Fernand Isidor Widal (1862-1929) Demonstrated specific agglutinins in the blood of Typhoid patient in 1896---- “The Widal Reaction”
  11. 11. History of typhoid epidemics
  13. 13. Infects roughly 21.6 million people each year * International Estimate Ramsden AE, Mota LJ, Münter S, Shorte SL, Holden DW. The SPI-2 type III secretion system restricts motility of Salmonella-containing vacuoles. Cell
  14. 14. Kills 200,000 people each year * International Estimate Ramsden AE, Mota LJ, Münter S, Shorte SL, Holden DW. The SPI-2 type III secretion system restricts motility of Salmonella-containing vacuoles. Cell
  15. 15. 62% of these occurring in Asia and 35% in Africa * International Estimate * Taylor TE, Strickland GT. Malaria. In: Strickland GT, ed. Hunter’s Tropical Medicine and Emerging Infectious Diseases. 8th ed. Philadelphia: WB Saunders, 2000:614-43.
  16. 16. Highest in Pakistan & India in Asian countries (451.7 per 100,000) * WHO Estimate * Bull World Health Organ vol.86 no.4 Genebra Apr. 2008
  17. 17. S P R E A D
  19. 19. Best prevention Scrub of them off your handsBest prevention Scrub them off your hands
  20. 20. Bacteria are better scientists than we are War of survival—they are working out very hard
  21. 21. RISK FACTORS
  22. 22. S. typhi are able to survive a stomach pH as low as 1.5. Antacids, (H2 blockers), PPI’s, gastrectomy, facilitate S typhi infection TYPHOID FEVER RISK FACTORS
  23. 23. Contaminated food, House hold with Cases, Inadequate hand washing, , drinking unpurified water, and living without a toilet TYPHOID FEVER RISK FACTORS Environmental/behavioral risk factors
  24. 24. PRESENTATION Incubation period is 7-14 days
  26. 26. Diffuse abdominal pain, Inflamed Peyer patches narrow the lumen--Constipation. Dry cough, dull frontal headache, delirium, increasingly Stupor & malaise FIRST WEEK OTHER SYMPTOMS
  27. 27. Rose spots, blanching, truncal, maculopapules usually 1-4 cm wide, < 5 in number; these generally resolve within 2-5 days (bacterial emboli to the dermis) FIRST WEEK OTHER SYMPTOMS
  28. 28. Distended abdomen, Soft splenomegaly, Relative bradycardia & dicrotic pulse (double beat, the second beat weaker than the first) SECONDWEEK
  29. 29. Patient may descend into the typhoid state---apathy, confusion, and even psychosis THIRD WEEK TYPHOID STATE
  30. 30. Necrotic Peyer patches, bowel perforation, Peritonitis, intestinal hemorrhage may cause death THIRD WEEK Week of complications
  31. 31. Fever, mental state, and abdominal distension slowly improve over a few days, complications may still occur in surviving untreated individuals FOURTH WEEK WEEK OF CONVALESCENCE
  32. 32. COMPLICATIONS pre inoculum
  34. 34. Bilateral Salmonella typhi breast abscess unmarried 35-year-old female without any predisposing conditions Singh S, Pandya Y, Rathod J, Trivedi S. Bilateral breast abscess: A rare complication of enteric fever. Indian J Med Microbiol [serial online] 2009 [cited 2009 Oct 16];27:69-70. Available from: http://www.ijmm.org/text.asp?2009/27/1/69/45176
  38. 38. Morbidity 55.4% mortality 28.5 % INTESTINAL PERFORATIONS 5% of people withtyphoid fever experience this complication DS00538 April 10, 2008© 1998-2009 Mayo Foundation for Medical Education and Research (MFMER). Typhoid enteric perforation, Dr Y. Akgun *, B. Bac, S. Boylu, N. Aban, I. Tacyildiz, British Journal of Surgery Volume 82 Issue 11, Pages 1512 - 1515 Published Online: 8 Dec 2005
  39. 39. Ileum especially distal ileum,jejunum usually doesnot perforate in typhoid, usually happens in the third week
  40. 40. MECHANISM OF INTESTINAL PERFORATION Intestinal peyer’s patches
  41. 41. 2 or 3 weeks hx of disease, with suddenly worsening of pain & general conditions, Tenderness starts in his right lower quadrant, spreads and eventually becomes generalized, Guarding , (seldom the board-like rigidity) Erect film, shows gas Under diaphragm (50% positive) lateral decubitus film, shows gas under his abdominal wall PRESENTATINPERFORATION The bradycardia and leucopenia of typhoid may occasionally mask the tachycardia and leucocytosis of peritonitis
  43. 43. If peritonitis seems to be localized, signs confined to only part abdomen, general condition is good, patient not deteriorating, consider non-operative treatment. CONSERVATIVE SURGICALVS If signs of generalized peritonitis, do a laparotomy
  44. 44. “Suck and drip” Resuscitation, antibiotics, pass a NG-tube, Monitor abdominal tenderness, pulse, temperature, white blood count. If any of these rise, suspect that peritonitis is extending, so take an erect X-ray film of his abdomen CONSERVATIVE MANAGEMENT
  46. 46. Do not forget to cover anaerobes and gram negative bacteria along with salmonella
  47. 47. Operate as early as possible, Do as much as necessory & as little as possible SURGICAL MANAGEMENT PREPARATION Adequately resuscitate, Maintain good urine output, pass nasogastric tube down, Start chemotherapy.
  48. 48. *Agbakwuru EA, Adesunkanmi AR, Fadiora SO, Olayinka OS, Aderonmu AO, Ogundoyin OO et al A review of typhoid perforation in a rural African hospital. West African Journal of Medicine 2003; 22(1):22- 25. (13 kb) Abstract only SurgerySteps
  49. 49. SurgerySteps
  50. 50. SurgerySteps
  51. 51. SurgerySteps
  52. 52. SurgerySteps CLOSE THE ABDOMEN Completely Without drains Drains are counter productive
  53. 53. POSTOPERATIVELY Fever usually subsides in 4 or 5 days Nourish patient as early as possible ICU care and monitoring Continue chemotherapy 14days
  54. 54. S P E C I M E N S John Hunter (1728-1793)
  55. 55. INTESTINAL HEMORRHAGE Occurs in 10-20 per cent of the cases
  56. 56. Intestinal bleeding is often marked by a sudden drop in blood pressure and shock, followed by the appearance of blood in stool Hemorrhagepresentation
  57. 57. replace the blood loses. Bleeding usually stops spontaneously Only operate if bleeding is persistent, or alarmingly INTESTINAL HEMORRHAGE
  58. 58. Surgery Intestinal Hemorrhage
  60. 60. Occurs in 1-2% of cases *According to Indian study 8% More common in children Antibiotic resistance & virulence of bacteria *M.L. Kulkarni, SJ. Rego, Department of Pediatrics, J.J.M. Medical College, Davangere 577 004. Acute Acalculous CholecystitisTYPHOID
  61. 61. Acute Acalculous CholecystitisTYPHOID *Thickened gall bladder wall, sonographic Murphy's sign, pericholicystic collection in the absence of gall stones *Subha Rao SD, LewinS, Shetty B, et al. Acute acalculous cholecystitis in typhoid fever. Indian Pediatr 1992, 29: 1431-1435.
  62. 62. Acute Acalculous CholecystitisTYPHOID Unlike other AACs, antibiotic therapy is the recommended treatment for Typhoid AAC
  63. 63. Chronic Cholecystitis (Carriers)TYPHOID Excretes bacteria in stools for more > 1 year1-4% of non-treated infected patients become chronic carriers Patients with cholelithiasis, biliary anomalies, females, Salmonella can be cultured from stools, duodenal aspirate, gall stones
  64. 64. Mary Mallon (September 23, 1869 – November 11, 1938) Forcibly quarantined twice, she infected 47 people, three of whom died. She died in quarantine.
  65. 65. Chronic CholecystitisTYPHOID Biliary anomalies, stones--requires cholecystectomy + antibiotics 4-6 weeks antibiotic treatment
  68. 68. Typhoid Enteric Perforation: Prognostic Factors an Experience with 76 Patients J Ayub Med Coll AbottabadJan - Mar 2000;12(1):49-52.Department of Surgery, Khyber Teaching hospital, Peshawar
  69. 69. Arkadiy Stavrovskiy, Typhoid. 1932 Oil on canvas
  70. 70. OIL ON CANVAS
  71. 71. Ty21a—Oral live attenuated vaccine
  72. 72. Vi-CPS— parenteral vaccine
  73. 73. TYPHOID Surgical Complications TYPHOID ical ati TYPHOID Surgical Complications TYPHO Sur Co TYPHOID Surgical Compli OID gical plications l ications T Surgi Complica PHOID urgical Complications TYPHOID Surgical Complicationsplica Good food handling & water sewage treatmentcan eliminate typhoid Prompt anntibiotic therapy can save many lives—take it a serious job Severe vomiting, diarrhoea & abdominal distension--- complicated, admit them & give IV antibiotics and support Prognosis of complications depends on the time-lapse b/w onset & treatment take home message killer salmonella formidable
  74. 74. w w w . s l i d e s h a r e . c o m