Management of Typhoid Intestinal Perforation which is a common and the most dreaded surgical complication of Typhoid fever.
This menace is still on the rise in low and medium income countries where we still battle with lack of potable water and open defecation.
This presentation is especially targeted at trainee surgeons in Nigeria and Medical Students also who may find it worthwhile.
Typhoid enteric perforation: A febrile killer!KETAN VAGHOLKAR
Typhoid enteric perforation still happens to be the most lethal complication of typhoid fever. Even in urban settings the condition is misdiagnosed causing death. A careful history followed by aproper clinical examination can still help in proper and pronpt diagnosis of this condition.
Typhoid enteric perforation: A febrile killer!KETAN VAGHOLKAR
Typhoid enteric perforation still happens to be the most lethal complication of typhoid fever. Even in urban settings the condition is misdiagnosed causing death. A careful history followed by aproper clinical examination can still help in proper and pronpt diagnosis of this condition.
Typhoid perforation is a serious complication of typhoid fever, a bacterial infection caused by Salmonella typhi. It occurs when the infection causes a hole to form in the wall of the intestine, leading to the leakage of contents from the intestine into the abdominal cavity. This can cause severe infection and inflammation of the abdominal cavity, known as peritonitis.
The symptoms of typhoid perforation may include severe abdominal pain, fever, nausea and vomiting, diarrhea or constipation, and signs of shock such as low blood pressure and rapid heart rate. In some cases, there may also be visible signs of a perforation, such as a palpable abdominal mass or signs of fluid accumulation in the abdomen.
The diagnosis of typhoid perforation is typically made through a combination of physical examination, laboratory tests, and imaging studies such as X-rays or CT scans. Treatment typically involves surgical repair of the perforation and aggressive management of the infection and inflammation. This may include antibiotics, intravenous fluids, and other supportive care measures such as pain management and nutritional support.
It is important to seek prompt medical attention if you suspect you or someone you know may have typhoid fever or typhoid perforation. Early diagnosis and treatment are essential for a successful outcome and to prevent further complications.
Shock is the state of not enough blood flow to the tissues of the body as a result of problems with the circulatory system.Initial symptoms may include weakness, fast heart rate, fast breathing, sweating, anxiety, and increased thirst. This may be followed by confusion, unconsciousness, or cardiac arrest as complications worsen.
Shock is divided into four main types based on the underlying cause: low volume, cardiogenic, obstructive, and distributive shock. Low volume shock may be from bleeding, diarrhea, vomiting, or pancreatitis. Cardiogenic shock may be due to a heart attack or cardiac contusion. Obstructive shock may be due to cardiac tamponade or a tension pneumothorax. Distributed shock may be due to sepsis, spinal cord injury, or certain overdoses.
The diagnosis is generally based on a combination of symptoms, physical examination, and laboratory tests. A decreased pulse pressure (systolic blood pressure minus diastolic blood pressure) or a fast heart rate raises concerns. The heart rate divided by systolic blood pressure, known as the shock index (SI), of greater than 0.8 supports the diagnosis more than low blood pressure or a fast heart rate in isolation.
Treatment of shock is based on the likely underlying cause.[2] An open airway and sufficient breathing should be established.[2] Any ongoing bleeding should be stopped, which may require surgery or embolization.[2] Intravenous fluid, such as Ringer's lactate or packed red blood cells, is often given.[2] Efforts to maintain a normal body temperature are also important.[2] Vasopressors may be useful in certain cases.[2] Shock is both common and has a high risk of death.[3] In the United States about 1.2 million people present to the emergency room each year with shock and their risk of death is between 20 and 50%
Splenic trauma - Causes, Complications, ManagementVikas V
Splenic Trauma - A detailed Presentation about Splenic Trauma, anatomy of the spleen, Causes of Trauma, Mechanism of Injury, Diagnosis, Management, Surgical management, Steps of Splenectomy, and Complications
Amebiasis is a parasitic infection of the intestines caused by the amoeba Entamoeba histolytica, or E. histolytica.
The symptoms of amebiasis include loose stool, abdominal cramping, and stomach pain. However, most people with amebiasis won’t experience significant symptoms.
Typhoid perforation is a serious complication of typhoid fever, a bacterial infection caused by Salmonella typhi. It occurs when the infection causes a hole to form in the wall of the intestine, leading to the leakage of contents from the intestine into the abdominal cavity. This can cause severe infection and inflammation of the abdominal cavity, known as peritonitis.
The symptoms of typhoid perforation may include severe abdominal pain, fever, nausea and vomiting, diarrhea or constipation, and signs of shock such as low blood pressure and rapid heart rate. In some cases, there may also be visible signs of a perforation, such as a palpable abdominal mass or signs of fluid accumulation in the abdomen.
The diagnosis of typhoid perforation is typically made through a combination of physical examination, laboratory tests, and imaging studies such as X-rays or CT scans. Treatment typically involves surgical repair of the perforation and aggressive management of the infection and inflammation. This may include antibiotics, intravenous fluids, and other supportive care measures such as pain management and nutritional support.
It is important to seek prompt medical attention if you suspect you or someone you know may have typhoid fever or typhoid perforation. Early diagnosis and treatment are essential for a successful outcome and to prevent further complications.
Shock is the state of not enough blood flow to the tissues of the body as a result of problems with the circulatory system.Initial symptoms may include weakness, fast heart rate, fast breathing, sweating, anxiety, and increased thirst. This may be followed by confusion, unconsciousness, or cardiac arrest as complications worsen.
Shock is divided into four main types based on the underlying cause: low volume, cardiogenic, obstructive, and distributive shock. Low volume shock may be from bleeding, diarrhea, vomiting, or pancreatitis. Cardiogenic shock may be due to a heart attack or cardiac contusion. Obstructive shock may be due to cardiac tamponade or a tension pneumothorax. Distributed shock may be due to sepsis, spinal cord injury, or certain overdoses.
The diagnosis is generally based on a combination of symptoms, physical examination, and laboratory tests. A decreased pulse pressure (systolic blood pressure minus diastolic blood pressure) or a fast heart rate raises concerns. The heart rate divided by systolic blood pressure, known as the shock index (SI), of greater than 0.8 supports the diagnosis more than low blood pressure or a fast heart rate in isolation.
Treatment of shock is based on the likely underlying cause.[2] An open airway and sufficient breathing should be established.[2] Any ongoing bleeding should be stopped, which may require surgery or embolization.[2] Intravenous fluid, such as Ringer's lactate or packed red blood cells, is often given.[2] Efforts to maintain a normal body temperature are also important.[2] Vasopressors may be useful in certain cases.[2] Shock is both common and has a high risk of death.[3] In the United States about 1.2 million people present to the emergency room each year with shock and their risk of death is between 20 and 50%
Splenic trauma - Causes, Complications, ManagementVikas V
Splenic Trauma - A detailed Presentation about Splenic Trauma, anatomy of the spleen, Causes of Trauma, Mechanism of Injury, Diagnosis, Management, Surgical management, Steps of Splenectomy, and Complications
Amebiasis is a parasitic infection of the intestines caused by the amoeba Entamoeba histolytica, or E. histolytica.
The symptoms of amebiasis include loose stool, abdominal cramping, and stomach pain. However, most people with amebiasis won’t experience significant symptoms.
this presentation includes anatomy physiology function of peritoneum ,also includes cause of peritonitis its severity ,various scoring system investigation and treatment.It includes the recent advancement and latest articles from latest books of surgery.
Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
The prostate is an exocrine gland of the male mammalian reproductive system
It is a walnut-sized gland that forms part of the male reproductive system and is located in front of the rectum and just below the urinary bladder
Function is to store and secrete a clear, slightly alkaline fluid that constitutes 10-30% of the volume of the seminal fluid that along with the spermatozoa, constitutes semen
A healthy human prostate measures (4cm-vertical, by 3cm-horizontal, 2cm ant-post ).
It surrounds the urethra just below the urinary bladder. It has anterior, median, posterior and two lateral lobes
It’s work is regulated by androgens which are responsible for male sex characteristics
Generalised disease of the prostate due to hormonal derangement which leads to non malignant enlargement of the gland (increase in the number of epithelial cells and stromal tissue)to cause compression of the urethra leading to symptoms (LUTS
Pulmonary Thromboembolism - etilogy, types, medical- Surgical and nursing man...VarunMahajani
Disruption of blood supply to lung alveoli due to blockage of one or more pulmonary blood vessels is called as Pulmonary thromboembolism. In this presentation we will discuss its causes, types and its management in depth.
Prix Galien International 2024 Forum ProgramLevi Shapiro
June 20, 2024, Prix Galien International and Jerusalem Ethics Forum in ROME. Detailed agenda including panels:
- ADVANCES IN CARDIOLOGY: A NEW PARADIGM IS COMING
- WOMEN’S HEALTH: FERTILITY PRESERVATION
- WHAT’S NEW IN THE TREATMENT OF INFECTIOUS,
ONCOLOGICAL AND INFLAMMATORY SKIN DISEASES?
- ARTIFICIAL INTELLIGENCE AND ETHICS
- GENE THERAPY
- BEYOND BORDERS: GLOBAL INITIATIVES FOR DEMOCRATIZING LIFE SCIENCE TECHNOLOGIES AND PROMOTING ACCESS TO HEALTHCARE
- ETHICAL CHALLENGES IN LIFE SCIENCES
- Prix Galien International Awards Ceremony
Flu Vaccine Alert in Bangalore Karnatakaaddon Scans
As flu season approaches, health officials in Bangalore, Karnataka, are urging residents to get their flu vaccinations. The seasonal flu, while common, can lead to severe health complications, particularly for vulnerable populations such as young children, the elderly, and those with underlying health conditions.
Dr. Vidisha Kumari, a leading epidemiologist in Bangalore, emphasizes the importance of getting vaccinated. "The flu vaccine is our best defense against the influenza virus. It not only protects individuals but also helps prevent the spread of the virus in our communities," he says.
This year, the flu season is expected to coincide with a potential increase in other respiratory illnesses. The Karnataka Health Department has launched an awareness campaign highlighting the significance of flu vaccinations. They have set up multiple vaccination centers across Bangalore, making it convenient for residents to receive their shots.
To encourage widespread vaccination, the government is also collaborating with local schools, workplaces, and community centers to facilitate vaccination drives. Special attention is being given to ensuring that the vaccine is accessible to all, including marginalized communities who may have limited access to healthcare.
Residents are reminded that the flu vaccine is safe and effective. Common side effects are mild and may include soreness at the injection site, mild fever, or muscle aches. These side effects are generally short-lived and far less severe than the flu itself.
Healthcare providers are also stressing the importance of continuing COVID-19 precautions. Wearing masks, practicing good hand hygiene, and maintaining social distancing are still crucial, especially in crowded places.
Protect yourself and your loved ones by getting vaccinated. Together, we can help keep Bangalore healthy and safe this flu season. For more information on vaccination centers and schedules, residents can visit the Karnataka Health Department’s official website or follow their social media pages.
Stay informed, stay safe, and get your flu shot today!
These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
Ethanol (CH3CH2OH), or beverage alcohol, is a two-carbon alcohol
that is rapidly distributed in the body and brain. Ethanol alters many
neurochemical systems and has rewarding and addictive properties. It
is the oldest recreational drug and likely contributes to more morbidity,
mortality, and public health costs than all illicit drugs combined. The
5th edition of the Diagnostic and Statistical Manual of Mental Disorders
(DSM-5) integrates alcohol abuse and alcohol dependence into a single
disorder called alcohol use disorder (AUD), with mild, moderate,
and severe subclassifications (American Psychiatric Association, 2013).
In the DSM-5, all types of substance abuse and dependence have been
combined into a single substance use disorder (SUD) on a continuum
from mild to severe. A diagnosis of AUD requires that at least two of
the 11 DSM-5 behaviors be present within a 12-month period (mild
AUD: 2–3 criteria; moderate AUD: 4–5 criteria; severe AUD: 6–11 criteria).
The four main behavioral effects of AUD are impaired control over
drinking, negative social consequences, risky use, and altered physiological
effects (tolerance, withdrawal). This chapter presents an overview
of the prevalence and harmful consequences of AUD in the U.S.,
the systemic nature of the disease, neurocircuitry and stages of AUD,
comorbidities, fetal alcohol spectrum disorders, genetic risk factors, and
pharmacotherapies for AUD.
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New Directions in Targeted Therapeutic Approaches for Older Adults With Mantl...i3 Health
i3 Health is pleased to make the speaker slides from this activity available for use as a non-accredited self-study or teaching resource.
This slide deck presented by Dr. Kami Maddocks, Professor-Clinical in the Division of Hematology and
Associate Division Director for Ambulatory Operations
The Ohio State University Comprehensive Cancer Center, will provide insight into new directions in targeted therapeutic approaches for older adults with mantle cell lymphoma.
STATEMENT OF NEED
Mantle cell lymphoma (MCL) is a rare, aggressive B-cell non-Hodgkin lymphoma (NHL) accounting for 5% to 7% of all lymphomas. Its prognosis ranges from indolent disease that does not require treatment for years to very aggressive disease, which is associated with poor survival (Silkenstedt et al, 2021). Typically, MCL is diagnosed at advanced stage and in older patients who cannot tolerate intensive therapy (NCCN, 2022). Although recent advances have slightly increased remission rates, recurrence and relapse remain very common, leading to a median overall survival between 3 and 6 years (LLS, 2021). Though there are several effective options, progress is still needed towards establishing an accepted frontline approach for MCL (Castellino et al, 2022). Treatment selection and management of MCL are complicated by the heterogeneity of prognosis, advanced age and comorbidities of patients, and lack of an established standard approach for treatment, making it vital that clinicians be familiar with the latest research and advances in this area. In this activity chaired by Michael Wang, MD, Professor in the Department of Lymphoma & Myeloma at MD Anderson Cancer Center, expert faculty will discuss prognostic factors informing treatment, the promising results of recent trials in new therapeutic approaches, and the implications of treatment resistance in therapeutic selection for MCL.
Target Audience
Hematology/oncology fellows, attending faculty, and other health care professionals involved in the treatment of patients with mantle cell lymphoma (MCL).
Learning Objectives
1.) Identify clinical and biological prognostic factors that can guide treatment decision making for older adults with MCL
2.) Evaluate emerging data on targeted therapeutic approaches for treatment-naive and relapsed/refractory MCL and their applicability to older adults
3.) Assess mechanisms of resistance to targeted therapies for MCL and their implications for treatment selection
Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists Saeid Safari
Preoperative Management of Patients on GLP-1 Receptor Agonists like Ozempic and Semiglutide
ASA GUIDELINE
NYSORA Guideline
2 Case Reports of Gastric Ultrasound
1. MANAGEMENT OF TYPHOID
INTESTINAL PERFORATION
PRESENTER : DR. ITANKA, UBONG COLUMBA
PGY2, SURGERY DEPARTMENT, UNIVERSITY OF ILORIN TEACHING HOSPITAL
SUPERVISING SENIOR REGISTRAR: DR. ADEPOJU
Saturday 5th November, 2022
3. Introduction
• Typhoid fever is a common,potentially fatal multisystemic infection that
has continued to be a public health problem in many developing countries .
• The surgical complications of typhoid fever are a cause of significant
morbidity and mortality.
• The management of Typhoid intestinal perforation TIP has posed a difficult
challenge due to its high morbidity and mortality.
• The management is multidisciplinary with surgery playing a major role.
4. Statement of Surgical Importance
• Being a common complication of Typhoid fever, the trainee surgeon
must have the basic knowledge of proper diagnosis, management and
prevention of this menace in the society.
5. Epidemiology
• According to WHO, incidence of Typhoid fever is between 20 and
30million cases with 1-4% mortality.
• 10% of patients with Typhoid fever will develop TIP
• Predominantly affects school age children 5-15yrs of age
• Children account for >50%.
• Commoner in low socio-economic age groups and also said to be
commoner during the rainy season.
• Sex M:F 1 in children, while in adults, M>F
• Children account for >50% of cases of TIP with a peak age of 5 to 9
years.
6. Historical Perspective
• The term typhoid derived
from the ancient Greek word
for cloud, was chosen to
emphasize the severity and
long lasting neuropsychiatric
effects among the untreated.
9. Historical Perspective
• Mary Mallon (September 23, 1869
– November 11, 1938),was
an American cook believed to have
infected between 51 and 122
people with typhoid fever.
• The infections caused three
confirmed deaths, with
unconfirmed estimates of up to 50.
• She was the first person in the
United States identified as
an asymptomatic carrier of the
pathogenic bacteria Salmonella
typhi.
10. Relevant Anatomy • Larger aggregations of lymphoid
tissue, each consisting of 10 to 200
follicles are present in the small
intestine called aggregated lymphatic
follicles or Peyer’s patches.
• Peyer’s patches always lie along the
antimesenteric border of the
intestine.
• They are most numerous and largest
in the terminal ileum.
11. Aetiology - Bacteriology
• Caused by the bacteria Salmonella
typhi and rarely by Salmonella
paratyphi
• Salmonella typhi, a gram negative,
flagellated, glucose fermenting,
aerobic bacilli that can also exist in
facultative anaerobic conditions
• S. typhi infects only humans
• S. paratyphi infects both humans and cattle
(serotype B). Can cause colonic perforation
• Possesses three major antigens: H or
flagellar antigen; O or somatic
antigen; and Vi antigen (possessed by
only a few serovars).
12. Aetiology – Risk factors
Bacterial Factors
• Infective dose: 105 for
salmonella typhi, more for s.
paratyphi
• Virulence: O, H and Vi antigens.
• Quorum sensing: Ability to
coordinate swarming and
biofilm production.
Host Factors
• Achlohydria
• Previous gastrectomy
• Antacids
• Immunosuppresion
• Cystic Fibrosis – Protective.
13. Pathogenesis – Natural History
i. Incubation: 10 to 14 days
ii. Active invasion
iii. Fastigium
iv. Lysis
v. Convalescence
14. Pathogenesis
Week 1
• Ingestion of contaminated food/water; bacilli evade stomach acidity
• Bacteria in small intestine; recognized by antigen presenting cells in
terminal ileum.
• Pass through Peyer's patches into blood stream (initial bacteremia;
detectable in blood – active invasion phase) then spreads to organs.
• Sensitization of the lymphoid tissue.
15. Pathogenesis
Week 2:
• Bacilli taken from circulation into the reticuloendothelial system
especially liver Kuffer cells; multiply; apoptosis of macrophages in RE
cells and release of the bacteria, PAMPS and lysozomal contents into
circulation and bile heralding the Fastigium phase.
• Bacteria secreted in bile; gall bladder wall: cholecystitis, empyema,
rupture, chronic carrier state.
• Invasion Payer's patches (previously sensitized); multiply; passed in
stool
16. Pathogenesis
• Week 3:
• Hypersensitivity in Peyer's patches; swelling , mucosal/
submucosal/muscular layers congestion – LYTIC PHASE.
• Blockage of capillaries; necrosis; ulceration; bleeding/perforation.
• Salmonella bacilli may be detectable in urine.
17. Pathogenesis - Summary
• Typhoid infection is faeco-oral in
nature and is due to faecal
contamination of food and
water.
18. Pathology – GROSS PATHOLOGY
• ULCERS: Shallow, irregular, oval
shaped, longitudinally oriented
on the antimesenteric border.
The base of the ulcers is black
due to sloughed mucosa.
Margins are slightly raised.
• Fibrosis not significant
• PERFORATION: Small or wide;
most are single and within 45cm
of terminal ileum.
20. Other Organs/Tissues of affectation
i)Mesenteric lymph nodes—haemorrhagic lymphadenitis.
ii) Liver—foci of parenchymal necrosis.
iii) Gallbladder—typhoid cholecystitis.
iv) Spleen—splenomegaly with reactive hyperplasia.
v) Kidneys—nephritis.
vi) Abdominal muscles—Zenker’s degeneration.
vii) Joints—arthritis.
viii) Bones—osteitis.
ix) Meninges—Meningitis.
x) Testis—Orchitis
21. Management
• Principles of management are
• Brief general assessment and SIMULTANEOUS resuscitation
• Appropriate investigations
• Source control: control of perforation & peritoneal
irrigation/toileting
• Eradicate the offending organism from the body
• Confirm absence of chronic carrier state before discharge
• Follow-up
• Prevention
22. Resuscitation
• Nil per os
• IV canula: fluids to correct dehydration and hemodynamic instability
• Intranasal Oxygen
• Nasogastric decompression
• Urethral catheter: 1 -2mls/kg/hr in children,0.5mls-1mls/kg/hr
• Fluid and electrolyte deficit correction + maintenance K
• Correction of anemia
• Analgesics
• Antibiotics therapy: Quinolone and metronidazole.
• Counsel on diagnosis, management options and prognosis
• Informed consent.
23. History
• Biodata: Age, sex, occupation of parents
• Presenting complaints: Fever and generalized body weakness
• Abdominal pain
• Abdominal distension
• Diarrhoea/Constipation
• Vomiting
• Melena
• Complications – Altered level of consciousness
• Source of drinking water/ Method of sewage disposal
• Review of other systems: N/B Typhoid is multisystemic.
25. Investigations
• Diagnosis can be made clinically with a high degree of accuracy.
Diagnosis of perforation may be difficult in
(a) a small group of patients who perforate under medical care and
(b) patients with protracted illness reaching hospital several days after
perforation.
27. Investigations
• Serum Electrolyte Urea and Creatinine: Hypokalemia, acidosis, ↑urea
• Full blood count: Anemia, lymphocytosis, neutropenia
• Plasma Total protein and albumin
• Group and crossmatch
28. Investigations – Support Diagnosis
• Microbiological Culture and Sensitivity: Blood, stool and urine.
• Gold standard: Bone Marrow aspirate.
• Widal Test: Depends on antibody response to O and H antigen. Not
specific, not sensitive.
• Others: TyphiDot, antiVi test
29. Investigations - Imaging
1. Chest Xray : Air under the diaphragm
2. Abdominal Xray(suppine and erect):
Dilated bowel loops, signs of
pneumoperitoneum – double bowel
sign, football sign, cupola sign,
falciform ligament sign
3. Abdominopelvic Ultrasound: Free
intraperitoneal fluid. Also to rule out
Appendicitis.
4. Computed Tomography abdomen:
early detection of pneumoperitoneum.
30. Source Control – Definitive Treatment
• The surgery done depends on the clinical state of the patient, number
of perforations, distance between perforations (if multiple) and from
the Ileocecal Junction and degree of peritoneal contamination.
31. Definitive Treatment
Options – Laparotomy + surgical options
1. Simple repair
2. Segmental resection and anastomosis
3. Limited Right Hemicolectomy
4. Enterostomy: In patients not fit, those with severe peritoneal
soilage or intestinal edema too extensive for safe anastomosis or
simple closure.
32. Laparotomy
• Anaesthesia: GA
• Position: Supine
• Pre-incision Antibiotics
• Routine skin preparation and draping
• Incision: Transverse supraumbilical in children. In older children and
adults, midline incision
33. • Access gained into peritoneal cavity
• Suction out the pus and debris
• Do quick exploration
• Identify the perforation(s). What is done depends on the number of
perforations, distance from ICJ and condition of neighbouring bowel
34. • Single perforation, > 10-15cm from ileocecal juncion:
Wedge resection with simple repair
35. • Multiple perforations far apart, none < 10-15cm from ICJ
- Close each perforation individually
• Multiple perforations, close together, none <10-15cm from ICJ
- Segmental ileal resection + ileo-ileal anastomosis
36. • Perforation (single or multiple) <
10-15cm from ICJ (this part is a
high pressure zone, prone to
leakage from closure of
perforations
- Limited Right hemicolectomy +
end-end (or end-side) ileo-
transverse anastomosis
37. • Do copious peritoneal lavage using 10-12L of N/S
• Fascia is closed.
• The skin is also closed at surgery using interrupted non-absorbable
sutures.
• Some surgeons leave the subcut and skin open, for delayed closure
(due to the risk of SSI)
38. Post-op
• Patient nursed in Intensive Care
• Fluid and Electrolyte balance
• Continue antibiotics
• Wound care
• Nutritional rehabilitation
39. Post-op Complications
• Prolonged Ileus: may last for several days and manifest as increasing
or persistent nasogastric drainage. Usually managed conservatively.
• Surgical site infection is one of the most common complications
occurring in 49–59% of patients with TIP.
• Anastomotic leakage
• Enterocutaneous fistula
• Intraperitoneal abscess: (7–9%) usually manifests as a return of fever
in a patient who had started to improve.
40. Post-op complications
• Adhesion intestinal obstruction
• Reperforation may occur at a new site in 7–9% of children with TIP. It
may be the result of an unidentified impending perforation or
progression of ongoing infection.
41. Prognosis
• Of the children treated for TIP, more than half develop one or more
complications.
• The single most important significant predictor of death in patients
with TIP is the duration of abdominal pain after 7 days.
• Delayed operation
• multiple perforations
• severe peritoneal contamination
42.
43. Follow up
• Do microscopy, culture and sensitivity of stool at follow up to confirm
absence of carrier state.
- If positive, health education and commencement of Quinolones ,
Septrin, Ampicillin
- Failed Medical Therapy? Cholecystectomy .
• Nutritional assessment
44. Prevention
• Primary Prevention:
1. General health promotion through health education, sanitation, Personal and
food hygiene, adequate potable water and curbing open defecation
2. Specific prophylaxis: Vaccination
• Secondary Prevention: Early diagnosis and treatment to prevent further
damage and spread.
• Tertiary Prevention: Limiting damage and rehabilitation .
46. Locoregional Challenges
• Poor sanitation
• Late presentation of patients
• Limited theatre space
• Shortage of manpower
47. Current Trends
• Typhoid conjugate vaccines: introduced to the Indian Market in 2018
and approved by the WHO.
48. Conclusion
• Typhoid Intestinal Perforation, most dreaded surgical complication of
typhoid infection.
• It is diagnosed clinically based on fever, abdominal pain/distension
and demonstrable peritonitis.
• Gold standard investigation is Bone aspirate.
• Surgery is the definitive treatment after adequate resuscitation and
appropriate antibiotics cover.