Typhoid ileal perforation is a frequent and severe surgical complication of typhoid fever, primarily affecting children in developing countries. Diagnosis is mostly clinical, and the main treatment is surgery, which includes options like perforation closure or segmental resection. Early diagnosis and effective management are crucial to minimize complications and mortality.

1. TYPHOID ILEAL
PERFORATION
Dr. Prince T. Ankrah
Snr. House Officer
(GENERAL SURGERY DEPARTMENT)
ENRH, December 2018.

2. OUTLINE
• INTRODUCTION
• EPIDEMIOLOGY
• AETIOLOGY
• PATHOPHYSIOLOGY
• CLINICAL FEATURES
• INVESTIGATIONS
• MANAGEMENT
• POST OP COMPLICATIONS
• TAKE-HOME POINTS

3. INTRODUCTION
The most common surgical complication in cases of
typhoid fever.
Mainly a problem in developing countries due to poor
sanitation and late diagnosis/proper management.
Diagnosis is mainly clinical
Surgery remains the gold standard of treatment

4. EPIDEMIOLOGY
• Global incidence of typhoid fever is 21million cases annually
with 1-4% mortality
• Children account for >50% of all cases of typhoid ileal
perforation with peak age of 5-9years.
• Has higher incidence in rainy season.

5. Aetiology
• Salmonella Typhii
• And rarely by Salmonella Paratyphii A, B,C.
• Transmission is mainly via feco-oral route.

6. Pathogensis
• S. typhi and paratyphi enter the host’s system primarily via
the distal ileum
• Attachment to the epithelium over clusters of lymphoid
tissue in the ileum (Peyer patches).

7. 1.
• Ingestion of contaminated food
2
• Intestinal mucosa invasion of ingested bacilli
3
• Taken up & transported to regional lymph node
4
• Multiplication in the intestinal lymphoid tissue
5
• Interaction with enterocytes & M cells (ileal Peyer’s patches)
6
• Entry of bacilli into the bloodstream
7
• Invasion of the gallbladder, biliary system and lymphatic tissues of the bowel
8
• Passage into the intestinal tract (stool)

8. CLINICAL FEATURES
• History of fever, 2-3weeks preceding the onset of abdominal
pain.
• Abdominal pain
• ± hematochezia prior to onset of pain
• Diarrhea or constipation.
• ± jaundice may be a complaint.

9. ON GENERAL EXAMINATION
Depending on the stage and severirty of the illness one could notice
• A very ill-looking patient
• Dehydrated
• Pale
• Febrile
• Wasted
CVS- there could be signs of shock
CHEST- usually clinically clear but crepitation could indicate pneumonia
co-morbidity

10. ABDOMEN
• Generalized tenderness
• Rebound tenderness
• Guarding
• Rigidity
• Diminished or absent bowel sounds
• Tenderness and fullness in the recto-vesical or recto-uterine pouch,
suggesting a pelvic collection of pus.
• Blood may be seen on the examining finger in patients with bleeding.

11. INVESTIGATIONS
Diagnosis is usually clinical, based on a good Hx + PE findings.
Investigations done are usually to:
Support the diagnosis
Identify deficits & likely complications
Ascertain fitness of the patient for surgery
FBC, BUE & Cr, BF for MP’s,GXM, plain CXR, ABD xray, blood & urine
cultures

12. INITIAL MANAGEMENT
• Correction of fluid and electrolyte deficits
• Gastric decompression (NG tube)
• Urethral catheter to monitor fluid output
• Blood transfusion if warranted
• IV antibiotic therapy
• Antipyrexics

13. DEFINITIVE MANAGEMENT
SURGERY IS MAINSTAY to get perforation corrected. Could be achieved
by laparotomy + options:
1. Simple closure of perforation
2. Segmental resection and anastomosis
3. Enterostomy

14. SIMPLE CLOSURE RESECTION & ANASTOMOSIS ILEOSTOMY
• single perforation
• perforations far
apart
• if the number of
perforations are so
numerous that
resection may result
in a short gut.
• Large solitary
perforation
• Multiple perforation in
close vicinity to each
other.
• Adjacent bowel is
friable/ near perforation
• The perforation (if single) or
the proximal and distal ends
(following segmental
resection) of the intestine are
exteriorised as stoma, to be
closed at a later date when
oedema has subsided and the
patient is fit(8-12weeks).
• An enterostomy is performed
if the child is too sick or
intestinal oedema is too
extensive for safe
anastomosis or simple
closure.

17. POST OP MANAGEMENT
• Strict fluid and electrolyte mgt
• Antibiotic cover
• Correction of anemia
• Close monitoring of vital signs
• Daily monitoring for intra-abdominal collection
• Wound dressing
• Adequate nutritional support

18. Post OP complications
• Prolonged ileus
• Surgical site infection
• Abdominal wound dehiscence
• Anastomotic leakage or complete breakdown of the anastomosis
• Enterocutaneous fistula
• Intraperitoneal abscess
• Adhesion intestinal obstruction
• Transient psychosis
• Electrolyte imbalance

19. TAKE HOME POINTS
• Ileal perforation is the most common and serious surgical
complication of typhoid infection especially in developing
countries.
• Early diagnosis, adequate initial resuscitation, and proper
choice of surgical procedure go a long way to reduce its
morbidity and mortality.

20. References