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Typhoid perforation is a serious complication and remains a significant surgical problem in developing countries, where it is associated with high mortality and morbidity, due to lack of clean drinking water, poor sanitation and lack of medical facilities in remote areas and delay in hospitalization.
Patients and methods:
The study is prospective descriptive study carried out during period of 3 years from 15th June 2006 to 14th June 2009 at department of surgery unit II, Chandka Medical College Teaching Hospital Larkana. A total of 62 patients diagnosed with typhoid illeal perforation admitted through OPD and Emergency department were included in the study. A written informed consent was obtained from each patients before enrolling them to study, the data was collected on printed proforma and included demographic area, clinical features, laboratory investigations, x-rays and ultrasonography findings , and operative findings, duration of hospital stay, postoperative complications, and mortality.
A total of sixty Two (62) patients were diagnosed with typhoid illeal perforation during the period under review.
There were 47 (75.8 %) males and 15 (24.2%) females with age ranging from 13 to above 50years.
The majority of patients presented with abdominal pain 58 (93%), fever 53 (85%), and 47(75%) abdominal distention. Widal test was positive in 41(66%) patients and pneumoperitoneum was identified in chest radiographs of 45(72.5%) patients and multiple air fluid levels in abdominal radiographs of 48(77%). Ultrasonography of abdomen and pelvis showed intraperitoneal collection in 91.93% (n=57). Peroperatively single perforation was found in 50 (80.64%) and two perforations in 09 (14.5%) patients and 03 (4.83%) patients were found to have multiple perforations. 22 (35.48%) patients developed postoperative wound infections, 06 (09.67%) patients developed respiratory tract infections, 06 (9.6%) patients developed fecal fistula, and 10 (16.12%) patients developed septicemia and 06 (9.6%) developed shock. Mortality was 24.1% (15 ).
The typhoid ileal perforation is still carries high morbidity and mortality. The typhoid ileal perforation should always be treated surgically. There are many operative techniques to deal typhoid ileal perforation but no one is fool proof. Regardless of the operative technique, timely surgery within 24 hours with adequate and aggressive resuscitation is a way to decrease the morbidity and mortality.
Typhoid fever is a common worldwide illness1 and Typhoid perforation of gut is its serious complication which carries a high mortality and morbidity in developing countries. Its real impact of the disease is difficult to estimate because the clinical picture is often confused with other febrile infections and often is undetected due to lack of specific and sensitive diagnostic tools in remote areas with scarce medical facilities. So majority of cases go undiagnosed until complicated.2 The purpose of our study was to add to the knowledge of the disease in this part of the world and to share our experience of clinical profile in management of typhoid ileal perforation over past 3 years.
PATIENTS AND METHODS
This study is a prospective descriptive study carried out during period of 3 years from 15th June 2006 to 14th June 2009 at Department of Surgery Unit II, Chandka Medical College Teaching Hospital Larkana. A total of 62 patients admitted through OPD and emergency department and diagnosed with typhoid illeal perforation on the basis of clinical features, investigations and preoperative findings were included in the study. Patients under 13 years or with generalized peritonitis due to other causes such as perforated appendicitis, peptic ulcer perforation, ectopic pregnancies, traumatic perforations or idiopathic intra-abdominal abscess were excluded from the study. A written informed consent was obtained from each patients before enrolling them to study, the data was collected on printed proforma and included demographic area, clinical features, laboratory investigations, x-rays and ultrasonography findings , and operative findings, duration of hospital stay, postoperative complications, and mortality. Widalââ‚¬â„¢s test / Typhidot was done preoperatively in majority of cases in which there were a high index of suspicion of typhoid fever ,other wise it was done postoperatively after typical findings were noted. After thorough preoperative resuscitation which included intravenous fluid and electrolyte replacement, commencement of intravenous broad spectrum antibiotics, gut decompression by NG tube, exploratory laparotomy was performed through midline incision. Operative findings, and operative procedures performed were recorded and edge biopsy at the perforation site or the resected specimen was sent for histopathological examination. The peritoneal cavity was then irrigated with 3-5 liters of warmed normal saline. Drains were kept in right paracolic gutter and the pelvic cavity. The postoperative complications were recorded and included wound infection, wound dehiscence, respiratory tract infections, residual intra-abdominal abscess, faecal fistula and death. The data analysis was done using SPSS version 10.
A total of 62 patients were included in the study in a period under review. There were 47 (75.8 %) males and 15 (24.2%) females with male to female ratio of 3:1. The age ranged from 13years to above 50 years as shown in table 1.
Table No.01 ( Age Distribution )
No: of patients
Around 93% (n=58) patients presented with abdominal pain, 85% (n=53) with history of fever, 75% (n=47) with abdominal distention, were the main symptoms with constipation and diarrhea and vomiting in 41(66.12) and 32 (51.61) respectively.64 %( n=40) with dehydration, 24 %( n=15) with shock as shown in table 2. The fever perforation intervals are shown in table 3.Widal test was positive in 41(66%) patients. Preoperative chest radiographs revealed pneumoperitoneum in 72.5% (n=45) patients and abdominal radiographs showed multiple air fluid levels in 77 %( n=48) patients. Ultrasound of abdomen detected free peritoneal collection in 57 patients (91.93%) cases, as shown Table 04.
Table No: 02 ( Clinical Presentation )
No of patients
Table No. 03 (Fever perforation interval)
No of patients
Table No. 04 (Findings on investigations)
Widalââ‚¬â„¢s test or typhidot
Multiple air fluid levels
Free fluid in peritoneal cavity
Exploratory laparotomy was carried in all cases. It was performed within 24 hours of admission in 74.2% (n=46), and after 24 hours in rest of the cases 25.8% (n=16) due to delay in resuscitations. Per operatively, peritoneal cavity was heavily contaminated in 10 patients while in 52 cases the peritoneal cavity was found in comparatively better condition. Single perforation was found in 80.64% (n= 50) patients, 14.5 %( n=09) patients had two perforations and 04.83 %( n=3)) patients had multiple illeal perforations, as shown table no. 05
Table No. 05 (No. of perforations)
No. of perforations
No. of patients
Perforations were surgically treated depending upon the number of perforations, general health status of patient and degree of faecal contamination. In 41 patients perforations after freshening the ulcer were closed by single layered interrupted extra-mucosal technique with vicryle 2/0, 08 (12.9%) needed resection & anastomosis and in 10 patients(18.18%) loop ileostomy was made , while limited right hemicolectomy was performed in 4.8%(n=03) patients with multiple ileal perforations figure 01.
Drains were kept in all patients in right paracolic gutter and pelvic cavity.
Postoperatively 35.48% (n= 22) patients developed wound infections, 09.67% (n=13) patients developed respiratory tract infections, 9.6% (n=06) patients developed fecal fistula, and 16.12% (n=10) patients developed septicemia and 09.67% (n=6) developed shock as shown in table 6. Duration of hospital stay was under 10 days in 36 patients and more than a month in 3 patients as shown in table 7.Mortality was found to be 24.1%.
Table No. 06 ( Postoperative Complications)
No of patients
Respiratory tract infections
Table No. 07 (Duration of hospital stay)
Duration of hospital stay
Typhoid fever is recognized as a serious global health problem by WHO1. A worldwide annual incidence of 16ââ‚¬"33 million cases, with 500,000 to 600,000 annual deaths in endemic areas has been reported. The incidence of disease varies considerably in different parts of the world, 15-33% in West Africa and 1-3% in Egypt and Iran.2 The exact incidence in Pakistan is not known. The incidence of typhoid is highest in children and young adults between 5 and 19 years old3 in our study the incidence was found to be highest in young productive people with mean age ranging from 13 to 30 years, which is consistent with other studies carried out previously 4,5,6,7, and a male preponderance was also noticed as in other studies.8,9,10 In our study the 93% patients presented with abdominal pain and 85% with history of fever, 14.52% patients presented with perforation with no history of pyrexia (Ambulatory Typhoid). Furthermore Widal test was positive in 66% patients, whereas typhidot was positive in rest of cases postoperatively. 72.5% patients had pneumoperitoneum on chest, quite similar to those reported by many workers, which is 62.2% (Rathore et al, 1987) 70% (white et al, 1986) and 78% (Badejo and Arig Babu 1980).Absence of gas under diaphragm may be due to absorption of air from the peritoneal cavity especially in patients presenting late after perforation ( Nandkarni and settee 1981). 77 % patients had multiple air fluid levels on abdominal radiographs, and 92% patients had intraperitoneal collections on ultrasonography. All these findings are in consistent with other reports. 5,11,12
Exploratory laparotomy was carried in all cases.In around 25% patients,the delay in surgery was due to institution of resuscitative measures as most of the patients presented late in poor condition as they came from remote areas with scarce medical facilities. Regarding number and location of perforations, in our study 80.64% had single perforation 14.5 % had two perforations and 04.83 % patients had multiple perforations, and all the perforations were 5-60cm away from ileocaecal junction and along the antimesenteric border of the ileum, the figures are closer to previous reports. 10,11,12,13,14 In Literature it is usually advocated that the last 60 centimeters of the ileum should be resected. However in our study, the decision of surgical procedure to be performed was made on clinical presentation, general condition of the patient, degree of peritoneal contamination, number and location of perforations. In patients with good general health, single perforation and minimum contamination wedge resections and primary repair was done i.e.66%, but in patients with moderate peritoneal contamination and multiple perforations very close to each other, we opted for resection and anastomosis (13%). But in toxic and moribund patients (16%) with heavily contaminated peritoneal cavity, a temporary illeostomy was preferred since ileostomy carries the advantage of avoiding any intestinal suturing in septic tissues and the subsequent risk of postoperative anastomotic dehiscence. while limited right hemicolectomy was performed in 4.8%(n=03) patients with multiple ileal perforations with perforations very close to ileocaecal valve and
presence of gangrenous patches both on the caecal wall and around the perforation. These patients improved successfully. Drains were kept in all patients and all patients were given aggressive preoperative resuscitation and perioperative injectable quinolones as advocated by researchers and clinicians. 15,16,17,18
Postoperatively 35% of our patients developed wound infections, and 09% patients developed wound dehiscence, this is similar to other reports19. Furthermore in our study 16.12 % patients developed septicemia and 09.67% went into shock, this too is consistent to studies carried out in past. 15
Enterocutaneous fistula remain the most dreadful life threatening of all the postoperative complications as it may lead to dehydration, electrolyte disturbances, shock, cachexia, and death. In our study 9.6% patients developed enterocutaneous fistula consistent with other studies 15,20,21. A Fecal fistula may form due to leakage from anastomosis or primary repair, synchronous impending perforation missed at the time of initial surgery or due to development of metachronous perforation of diseased ileum. 22,23,24
In our series the Mortality was found to be 24.1%., and was highest in patients who developed fecal fistula, in contrast to other studies where death is attributed to septicemia most commonly 20,12.
Typhoid fever is still a serious health problem in our setup it has a very high social and economic impact as well. It still carries a high mortality and morbidity. The high mortality and the morbidity are not dependent on the surgical technique only but on the clinical presentation of patient, general condition, duration of illness, perforation hospitalization interval and perioperative management also. So early detection of the disease, timely hospitalization, timely surgery, adequate and aggressive preoperative resuscitation, proper postoperative care with special consideration to nutrition, can help reduce its morbidity and mortality.