Although typhoid is common all over the developing world, a patient is more likely to perforate his gut in some countries than in others. In areas where perforation is common (West Africa, particularly Ghana), it is one of the commonest causes of an acute abdomen. 90% of of patients, many of them children, perforate outside hospital. Less often, you will also see the serious intestinal bleeding that typhoid can also cause.
A typhoid perforation is seldom dramatic, because loops of diseased gut stick together, so that leaking gut contents do not spread widely; sometimes the leak is small. A patient can seldom tell you the moment it happened, as he usually can when a peptic ulcer perforates. If he is already very ill, he may not even complain that his pain has got worse. When you examine him, his signs will depend on: (1) How long ago his gut perforated, and (2) how localized his peritonitis is.
You will seldom miss a typhoid perforation if: (1) You examine the abdomens of all patients with typhoid fever daily. Perforations which occur in hospital are easily missed. (2) You think of it in any patient who has acute abdominal pain, and signs of peritonitis, during a febrile illness. If he has been toxic and feverish, and moaning with abdominal pain for 2 or 3 weeks, and then suddenly complains that his pain is worse, a typhoid ulcer in his ileum has probably perforated. This usually happens in the third week, but can occur in the first week, or during convalesence.
The gut in typhoid is oedematous and friable, so that surgery is difficult. If a perforation presents insidiously, and appears to be localized, and you are inexperienced, you will be wise to ''suck and drip him', and not to operate. If, however, his perforation is dramatic, it is likely to be early, and his peritonitis generalized, so operate. If he arrives late, his chances of death are 20[nd]30%. If he arrives early, and you can give him parenteral nutrition, and intensive care, and monitor his central venous pressure, it can be as low as 10%, or even 3%.
Alas, S. typhi is now chloramphenicol- and ampicillin-resistant in many areas. So adjust chemotherapy accordingly. When a typhoid ulcer perforates, many bacteria are released into the peritoneal cavity, including anaerobes. S. typhi is one of the least important.
When you operate, aim to do as much as is necessary and as little as possible. Remember that he has: (1) septicaemia, (2) generalized peritonitis, (3) dehydration and electrolyte imbalance, (4) immunosuppression which causes him to localise his infection badly. (5) Small gut which is thin and difficult to suture. When you have sutured it, a small leak easily becomes larger.
Bitar R, and Tarpley J, ''Intestinal perforation in typhoid fever', Reviews of Infectious Diseases 1985;7:257[nd]271. Fig. 31-9 TYPHOID FEVER. A, the characteristic appearance (''typhoid facies') of a patient with typhoid fever. B, the bacteriology of intestinal perforation in typhoid fever. Note the two phases of [f10]S. typhi [f11]bacteraemia (1 and 2), and the third phase of bacteraemia, with organisms from the gut, that follows perforation (3). After Bitar and Tarpley, partly hypothetical.
THE SURGERY OF TYPHOID [s8]PERFORATION AND BLEEDING Be sure that the staff of your outpatient department watch for typhoid perforations. There must be little delay between diagnosing a perforation and closing it. A patient's prognosis will depend on the interval between the onset of his illness, and his perforation; and between this, and its closure. So operate soon, if you decide to do so.
DIAGNOSING PERFORATION. Fever and headache at the onset of the illness, are followed by vomiting, abdominal pain, and distension. When he perforates, tenderness usually starts in his right lower quadrant, spreads quickly, and eventually becomes generalized. He usually shows guarding, but seldom the board-like rigidity characteristic of a perforated peptic ulcer.
Percuss his lower ribs anteriorly; if there is gas between them and his liver, the percussion note will be resonant (due to the absence of the normal liver dullness). His bowel sounds may be absent. Hypotension, oliguria, and bradycardia are terminal signs. If possible, culture his stools, if necessary more than once.
CAUTION ! The bradycardia and leucopenia of typhoid may occasionally mask the tachycardia and leucocytosis of peritonitis.
If he reaches hospital several days after the perforation, the diagnosis will be difficult, because abdominal distension will overshadow other signs of perforation.
X-RAYS. Take an erect film, and look for gas under his diaphragm (50% positive). If he is too weak to sit up, take a lateral decubitus film, and look for it under his abdominal wall (66-4). This is a very useful sign. You may also see loops of his small gut dilated with gas, usually without fluid levels.
THE DIFFERENTIAL DIAGNOSIS includes appendicitis (12.1), a perforated peptic ulcer (11.2), perforations from other causes, such as spreading PID (6.6), or strangulated gut as with volvulus (10.9), and necrotizing amoebic colitis (31.11).
Suggesting appendicitis[md]pain starting over his umbilicus and moving to his right iliac fossa; pain precedes fever. If acute appendicitis has reached the stage of toxaemia, dehydration, and peritonitis, the differential diagnosis may be impossible before laparotomy.
Suggesting a perforated peptic ulcer[md]a sudden onset, and a history of ulcer symptoms.
Suggesting necrotizing amoebic colitis[md]a history of diarrhoea (especially with the passage of blood and mucus), followed by acute pain in his right lower quadrant, with guarding and a silent abdomen. Look for trophozoites in his stools.
MANAGEMENT. Here are some guidelines:
If he has signs of generalized peritonitis, but is not moribund (common), do a laparotomy.
If peritonitis seems to be localized (common), with signs confined to only part of his abdomen, and his general condition is good, and he is not deteriorating, consider non-operative treatment.
If he is moribund 36 to 48 hours after a perforation, with a distended or board-like abdomen, a thready pulse, and a very low blood pressure, his prognosis is hopeless.
If surgical treatment is difficult or impossible, you may have to treat him non-operatively.
If he passes melaena stools (or occasionally frank blood), replace the blood he loses. Bleeding will probably stop spontaneously. Only operate if he bleeds persistently, or alarmingly. His bleeding ulcers are in his distal ileum, but the ulcer which is bleeding may be difficult to find. If you can find it, do a limited resection. If you cannot find it, open his gut (do an enterotomy 9.3) at the level you suspect. If you still cannot find it, you may have to resect up to 60 cm of his terminal ileum, or terminal ileum and colon (hemicolectomy, 66- 20).
RESUSCITATION is critical. Be prepared to rehydrate him vigorously (A 15.3). He may need 4 or more litres of intravenous fluid. Don't forget the potassium (A 15.3). If his haemoglobin is less than 80 g/l, give him blood. Monitor his urine output, and maintain his fluid balance, as in Section A 15.5. If possible monitor his central venous pressure.
CHEMOTHERAPY is needed by all patients. He needs antibiotics against S. typhi, and enteric Gram-negative bacilli, and anaerobes.
For Salmonella typhi, chloramphenicol 12.5 mg/kg 6-hourly. Usually 1 g 6-hourly, but up to 2 g 4-hourly for up to 5 days in very ill patients (12 g daily) followed by 250 mg 6- hourly for 14 days. The KCMC in Tanzania give 4 g 6-hourly (16 g daily). If possible, give some chloramphenicol intravenously initially.
Or, trimethoprim 200 mg 12 hourly. Decrease the dose if he has renal insufficiency. Trimethoprim deserves equal status with chloramphenicol as a first line drug.
Or, ampicillin, 25 mg/kg 6 hourly. Usually 2 g 6- hourly.
Or, amoxycillin, 12.5 to 25 mg/kg 6 hourly.
And, for enteric Gram-negative bacilli, gentamicin 2 mg/kg as a loading dose followed by 1.3[nd]1.7 mg/kg 8-hourly. Decrease the dose if he has renal insufficiency.
And, for anaerobes, metronidazole 15 mg/kg or 1 g as a loading dose, followed by 7.5 mg/kg 8-hourly. Usually 500 mg 8- hourly.
NASOGASTRIC SUCTION will empty the gas from his stomach, and, hopefully, diminish the distension of his small gut. Respiratory complications, particularly the aspiration of stomach contents, before, during, or after anaesthesia are an important cause of death.
NON-OPERATIVE TREATMENT [s7]FOR A TYPHOID PERFORATION INDICATIONS. A perforation which presents insidiously, and appears to be localized, particularly if you are inexperienced. Most cases are like this.
CONTRAINDICATIONS. A dramatic perforation, with signs of generalized peritonitis, especially if it is early. If so do a laparotomy (see below).
METHOD. Resuscitate him, give him antibiotics, and pass a nasogastric tube as above. Monitor his abdominal tenderness, and the size of his abdominal mass, if he has one. Both should get less, as in an appendix abscess (12.1). Monitor his pulse, his temperature, and his white blood count. If any of these rise, suspect that peritonitis is extending, so take an erect X-ray film of his abdomen.
If his response is favourable, taper off the above measures after a few days, and start giving him oral fluids.
Operate if: (1) There are general or local signs that his peritonitis is spreading. (2) He shows any signs of intestinal obstruction.
LAPAROTOMY [s7]FOR A PERFORATED TYPHOID ULCER PREPARATION. Make sure he is adequately resuscitated, he has a good urine output, he has a nasogastric tube down, and is on chemotherapy.
ANAESTHESIA. (1) Ketamine, tracheal intubation, and relaxants (A 8.4). (2) General anaesthesia, intubation, and relaxants (A 14.3). (3) If necessary, use local anaesthesia (A 6.7).
INCISION. Make a median or right paramedian incision, most of it below his umbilicus. As you incise his peritoneum, there will probably be a puff of gas, confirming that some hollow viscus has perforated. Insert your hand, and gently break up any fibrinous adhesions.
Expect to find: (1) Greenish ileal contents in his peritoneal cavity. (2) The last 60 cm of his ileum bright red, and the adjacent structures somewhat less so. (3) Friable oedematous ileum. (4) In late cases particularly, dilated loops of jejunum and proximal ileum. (5) Soft, soggy mesenteric lymph nodes. Aspirate as much of his peritoneal contents as you can, and send some for culture.
Start at his ileocaecal junction, hold his gut very gently with moist laparotomy pads, and work your way proximally until you reach healthy gut, or his ileo-jejunal junction. Look for one or more tiny perforations in his ileum. The jejunum does not perforate in typhoid. Typhoid perforations are usually in the centre of an ulcer, on the antemesenteric border of the ileum, not far from the caecum. Put a tag on each perforation you find, until you have found them all. There is usually only one, and there are rarely more than three. You may find adhesions, which you will have to divide very gently by sharp, or if they are thin, by blunt dissection.
CAUTION ! Handle his gut with the greatest possible care[md]it may come apart in your hands at any moment.
If a perforation is small ([lt]5 mm), you can: (1) Freshen its edges, by excising 1 mm of mucosa all round its circumference, and close it transversely with 2 or 3 ''all coats' sutures of continuous 3/0 chromic catgut, or interrupted 3/0 silk. If you put them through only part of the gut wall, they will cut out. Invert these ''all coats' sutures with a continuous layer of Lembert seromuscular sutures. (2) Close each perforation with a full-thickness figure of eight suture of 3/0 catgut, or ''Dexon', through all layers. If you wish, insert a second figure of eight suture to reinforce the first. (3) Insert an ileostomy tube (or a Foley catheter) through the perforation, tide him over the acute stage, and reoperate later to close the perforation.
If he has multiple perforations, or a large perforation with diseased gut, you have four choices:
(1) You can oversew each perforation or potentially leaky area, as described above. If he is desperately ill, he will probably not tolerate anything more than this.
(2) You can do an ileotransverse colostomy, with a mucous fistula, and repair this later (9.3, 29.7).
(3) If he is relatively fit, with a severely diseased segment of gut, or if there is alarming bleeding, you can resect the diseased segment, and do an end to end anastomosis, as in Fig. 9-9. Avoid resection if you can. His generalized peritonitis, and the friability of his gut, will make this difficult.
(4) You can exteriorize the diseased segment of his gut, as in Fig. 9-13. If he is very ill, and you think he needs something more than simple oversewing of his perforation, this will be simple and relatively atraumatic for him, and is unlikely to cause much bleeding. But his postoperative management will be difficult.
If he presents late, with a localized collection of pus (rare), drain it locally; this is not urgent.
DEALING WITH THE PERITONITIS depends on what you find.
If peritonitis is localized, do a local toilet only, and avoid spreading the infection to the rest of his peritoneal cavity. Had you known this earlier, you would probably have decided not to operate.
If peritonitis is generalized, wash out his entire peritoneal cavity with several litres of saline. Pour in a litre of warm saline, slosh it around with your hands, and then aspirate it. Repeat this three or four times. Add a gram of chloramphenicol or tetracycline to the last litre (6.2).
CLOSE HIS ABDOMEN completely without drains.
CAUTION ! Be quite sure to pack his skin and subcutaneous tissues open for secondary closure later (9.8).
POSTOPERATIVELY. He will have been ill for days, or sometimes up to 3 weeks, before surgery, and his preoperative metabolic abnormalities will still be imperfectly corrected. Manage him as for other kinds of peritonitis (6.2). Monitor him daily for the early detection of collections of intra-abdominal pus. Continue intravenous chloramphenicol at ordinary, rather than high, doses for two weeks. This will help to combat his typhoid, but not necessarily his peritonitis. Fever usually subsides in 4 or 5 days. Attend to other manifestations of the disease, and nourish him as early, and as well as the clinical situation and the available technology will allow (9.11, 58.11).
DIFFICULTIES [s7]WITH A TYPHOID PERFORATION Be prepared for wound sepsis (9.12), a burst abdomen (9.13), intestinal obstruction (10.13), intra-abdominal abscesses (6.3), fistulae (very serious, 9.14), anaemia and many weeks of inadequate nutrition and hospitalization, and particularly for respiratory complications (9.11). Finally, he may get an incisional hernia (14.13).
If you DON'T FIND A PERFORATION, there may not be one, and his peritonitis may be primary (haematogenous), or from some other cause. It is doubtful if typhoid ever causes peritonitis without perforation, but primary peritonitis without an established cause is common in Africa.
If he has SEVERE DIARRHOEA about the 4th day, it will be very difficult to treat, and may kill him. Replace his fluid loss energetically, and don't forget the potassium (A 15.5).
If he has RENEWED PAIN, and deteriorates postoperatively, suspect that he has had another perforation.
If he has a sudden spike of FEVER after about 5 days, when he should have recovered from his typhoid, and it is not malaria, suspect wound infection (9.12), a subphrenic abscess (6.4), pneumonia, or a faecal fistula (9.14).