1 s2.0 S1743919113000307 Main PDF
1 s2.0 S1743919113000307 Main PDF
1 s2.0 S1743919113000307 Main PDF
Review
a r t i c l e i n f o a b s t r a c t
Article history: Background: The management of ileal typhoid perforation is a challenging task in our environment. Lack
Received 27 December 2012 of incidence data base and poor nancial resources preclude adequate prevention of this public health
Received in revised form menace.
24 January 2013
Objectives: For now the focus will remain the effective and strategic management of this complication to
Accepted 29 January 2013
Available online 9 February 2013
reduce the morbidity and mortality.
Methods: 86 cases of ileal typhoid perforation were seen over a two year period. Most were male children
and male young adults. Data collection was by retrieving information from the medical records of Enugu
Keywords:
Management
State University of Science and Technology Teaching Hospital (ESUTH). All were resuscitated with 1v
Ileal perforation uids, iv antibiotics, nasogastric tube suction and where indicated blood transfusions. Majority had
Typhoid bacteriological, biochemical, haematological and radiological investigations. Laparotomy was undertaken
after adequate resuscitation.
Results: Most had been febrile for 2e6weeks prior to admission, with the majority having been labelled
resistant malaria cases. Most presented more than 24 h after onset of peritonitis and were therefore
explored late, some as late at 96 h. At laparotomy 97% had large volumes of pus and small bowel contents
in the peritoneal cavity and 3% had localized intraabdominal abscesses. No attempt at healing or omental
localization of the perforation was observed. Fifty two (60.5%) patient underwent simple closure, 18(21%)
had ileal resection and enteroanastomosis, 7(8.1%) had tube ileostomy, 5(5.8%) had primary suture and
proximal ileo-transverse anastomosis and 4(4.7%) limited right hemicolectomy. All had liberal peritoneal
lavage with normal saline.
The group that presented relatively early, with minimal pathological changes, had primary suture and
mortality in this groups was 11.5%. The group with gross pathological changes seen mainly in patients
that presented late had higher mortality rates, even as high as 50%. However our overall mortality rate
was 18.6%.
Conclusion: The authors afrm that typhoid ileal perforation must be treated surgically. Early presen-
tation and diagnosis, adequate resuscitation, prompt surgery and vigorous post-operative management
improved mortality rates. Clearly delays in presentation necessitating prolonged resuscitation and
therefore delayed surgery affected mortality.
2013 Published by Elsevier Ltd on behalf of Surgical Associates Ltd.
1743-9191/$ e see front matter 2013 Published by Elsevier Ltd on behalf of Surgical Associates Ltd.
http://dx.doi.org/10.1016/j.ijsu.2013.01.014
REVIEW
and safe anaesthesia, surgery is now routinely used to manage ileal 20(23.3%) patients were females giving a male to female ratio of 3:1.
perforation and offers the best hope of survival.3 The age distribution is depicted in Table 1 with the youngest patient
The preoperative diagnosis of perforation usually, is based on being 2 years of age, and oldest patient 56 years with mean age of
ndings of peritonitis in a patient with a history of prolonged febrile 25yrs. Fifty eight percent and 78% of patients were within their
illness. However with the increasing streams of antibiotic used it in second and third decades of life respectively. Sixty percent of cases
its management, dramatic changes in the clinical course of the occurred between the months of August and November.
disease and it dreaded complication, death from ileal perforation are Majority of the patients had a variable period of onset of typhoid
not so commonly seen in our environment. As such evaluation and fever ranging from one to six weeks and only 7 patients (8.1%) had
re-evaluation of the management strategies of typhoid and its been ill for less than one week before the onset of peritonitis.
complications need to be carried out periodically. Prevention is the (Table 2). Most of the patients presented more than 24 h after the
most effective way of dealing with this public health problem. onset of peritonitis and some as late as 96 h. Most of the patients
However for now lack of incidence data and inadequate nancial presented with abdominal pains, (90.7%) abdominal distention
resources in the developing countries such as ours preclude the 75.6%, nausea and vomiting 70.9%, constipation (54.7%) and
effective implementation of preventative strategies. fever(50.1%)(Table 3)The predominant clinical signs on presentation
It is now a settled issue that typhoid ileal perforation must be were the shocked state in 89.4% of cases, generalized abdominal
treated surgically.4 There are many methods of surgically treating distension (90.7%) tenderness with guarding and abdominal rigidity
typhoid ileal perforation viz primary closure, excision and closure, with absent bowel sounds indicating generalized peritonitis with
resection and primary anastomosis, limited right hemicolectomy paralytic ileus (70.9%)(Table 4). Few patients (20.7%) created clinical
and ileostomy5. However early daily diagnosis, prompt and ade- dilemma at presentation. These were patients who perforated while
quate resuscitation and early treatment avoid the need for exten- on anti typhoid/broad spectrum antibiotics therapy and they pre-
sive surgical procedure and is associated with low morbidity and sented clinically with distended but doughy feeling, mild tender
mortality6,19. Late presentation results in extensive pathological abdomen and were not febrile, yet they had underlying fulminating
changes in the terminal ileum and caecum and therefore requiring peritonitis. Table 4 shows the clinical signs.
more formidable and extensive surgical procedure such as resec- Results of investigation are shown in Table 5. Seventy seven
tion anastomosis and right hemicolectomy all of which contribute (89.5%) of the patients had pack cell volume (PCV) with 80% of
to higher morbidity and mortality.2,7 them having a PCV below 30, making a mean PCV of 24. The mean
white cell count was 4200 in 76(88.4%) of patients. Seventy four
2. Patients and methods percent (64 patients) who had serum electrolytes/creatinine done
had hypokalaemia as a prominent nding. More than half of the
This is a retrospective study of 86 patients who presented with typhoid ileal
perforation over a two year period (Jan 2007 and Jan 2009) in the surgical depart-
patients came with widal test done elsewhere and many of these
ment of Enugu State University of Science and Technology Teaching Hospital, Enugu were positive with titres of 1:160 or more for O and H antigens.
Nigeria. Stool culture was done in 32(37.2%) patients, but was only positive
All the patients were admitted through either the Out Patient Department or the in 2 patients. All the patients had HIV tests done routinely and
Accident and Emergency department of the hospital and diagnosed with typhoid
none in our series was positive. Erect Anterior chest x-ray was
ileal perforation, on the basis of its typical history and clinical examinations sup-
ported by radiological, laboratory investigations and conrmed by operative nd- performed in 58patients and 72.4% showed subdiaphramatic free
ings. Histopathological examination of the edge of the ileal perforation specimen air. Fifty seven (66.3%) patients had abdominopelvic ultrasound
was also a form of retrospective diagnostic conrmation. All the other causes of with 97% of patients showing free peritoneal uid typical of
peritonitis such as ruptured appendix, traumatic perforations, tuberculosis enteric peritonitis.
perforations, perforated peptic ulcer and others were excluded from the study.
Most of the patients had received no proper treatment for their illness and
At surgery 96.8% of our patients had generalized peritonitis with
almost all the patients had sought initial medical attention from untrained medical varying amount of small bowel contents and pus in the peritoneal
practitioners and only presented to us following a dramatic worsening of their cavity. There was no tendency towards walling off of the perfo-
symptoms of peritonitis. ration by the omentum other than adherence of perforated ileal
The data of each patient was collected in a Performa form designed for the study
loop to adjacent loops of bowel. In few cases the ileum was severely
and it included the demographic details of age, sex and ethnicity. Also included in
the proforma are duration of symptoms prior to presentation, clinical presentations, diseased and the caecum was phlegmonous with the ascending
investigations, duration between onset of peritonitis and surgical operation. Severe colon and showed patches of ischaemia. Eighty percent of the ileal
and sudden onset of abdominal pain corresponds to the time of intestinal perfo- perforations were located within 60 cm of the ileocacal valve.
ration and the onset of peritonitis. Also recorded were pre-operative resuscitative About 80% of the perforations were less than 1 cm while the rest
measures, the operative ndings, procedure performed, post-operative complica-
tions and length of hospital stay.
were 1.5 cme2 cm in diameter. Most perforations were round or
All the patients were resuscitated with intravenous uids, nasogastric decom- ovoid and all were typically laid along the antimesenteric border of
pression of the stomach, vital signs and urethral catheterization for urinary output the ileum. Sixty one (71%) patients had a single perforation while
monitoring. Intravenous antibiotics consisting of third generation cephalosporin, 25(29.1%) had more than one perforation (see Tables 6e8).
metronidazoles were commenced immediately. Investigations done included, full
Fifty two (60.5%) patients in our series underwent simple one or
blood count, Widal test, blood and stool cultures, serum electrolytes and creatinine,
chest and erect abdominal x-rays, and abdominal-pelvic ultrasound scans. two layer closure using 2/0 vicryl sutures after biopsies were taken
Upon adequate resuscitation as shown by blood pressure 100 mmHg systolic
and urinary output of 30 mls/hour, laparotomy through a midline abdominal
incision under general anaesthesia was carried out. At surgery, the operative nd-
ings were noted, the type of surgical procedure carried out was stated. All patients Table 1
had peritoneal lavage with copious volumes of Normal saline. All had mass closure of Age distribution of patients.
abdominal wound with No.2 Nylon sutures with intra-abdominal drain left in-situ. Age (yrs) Number Percent
The post-operative complications as well as the mortality for each set of oper-
ative procedures and overall mortality were also recorded. 0e9 17 19.8%
10e19 33 38.3%
20e29 17 19.8%
3. Results 30e39 9 10.5%
40e49 7 8.15
50e59 3 3.5%
Eighty six patients were reviewed for ileal perforation second-
Total 86 100%
ary to typhoid fever. Sixty six (76.7%) patients were males and
REVIEW
Table 2 Table 4
Duration of symptoms prior to admission. Ellcited clinical signs/ndings.
Table 3
Clinical symptoms recorded on admission. Table 5
Investigations prior to admission or before surgery.
Symptom No. of cases Percent
Investigation No. of cases Percent
Abdominal pain 78 90.7%
Nausea and vomiting 61 70.9% Pcv 77 89.5%
Diarrhea 25 29.0% 67.4% 64 74.4%
Constipation 47 54.7% Widal test 58 67.4%
Abdominal distension 65 75.6% White cell count 76 88.4%
Fever 43 50.1% Blood culture 10 11.6%
Cold sweat 27 33.4% Stool culture 32 37.2%
Confusion and agitation 15 17.4% Erect abdominal X-ray 58 67.4%
Jaundice 5 5.8% Abdominal pelvic ultrasound 57 66.3%
REVIEW
Table 6 Table 8
Duration of perforation prior to operation. Number of ileal perforations.
Table 7 Table 9
Operative ndings. Operative procedures performed and mortality rate for each procedure.
Distance of perforation No. of cases Percent Procedure No. of cases Deaths Mortality rate
from ileo-caecal valve Simple closure & drainage 52 6 11.5%
0e19 cm 23 26.7% Resection & anastomosis 18 5 27.7%
20e39 38 44.2% and drainage
40e59 13 15.1% Ileostomy and drainage 7 2 28.6%
60e79 8 9.3% Primary suture with ileo- 5 1 20%
80e99 cm 4 4.7% transverse anastomosis
>100 cm Nil 0% Limited right hemicolectomy 4 2 50.0%
Total 86 100% Total number of deaths 16 Over mortality 18.6%
REVIEW