Typhoid Typhoid

Dr. Ashok Jaisingani Dr. Ashok Jaisingani

Introduction Introduction

► Typhoid fever is caused by gram –ve Typhoid fever is caused by gram –ve organism salmonella typhi also called as organism salmonella typhi also called as typhoid bacillus. typhoid bacillus.

►Most common in developing countries in Most common in developing countries in tropics tropics

► Poor hygiene and inadequate sanitary Poor hygiene and inadequate sanitary condition attributed to entry of organism condition attributed to entry of organism into GIT. into GIT.

► Surgical importance of disease is because of Surgical importance of disease is because of perforation of typhoid ulcer. perforation of typhoid ulcer.

Pathology Pathology

►Organisms enter into GIT through ingestion of Organisms enter into GIT through ingestion of contaminated foods and water. contaminated foods and water.

► In GIT organism colonize the peyer’s patches In GIT organism colonize the peyer’s patches of terminal ileum causing the hyperplasia of of terminal ileum causing the hyperplasia of lymphoid follicles followed by necrosis and lymphoid follicles followed by necrosis and ulceration ulceration

►Microscopic picture show erythrophagocytosis Microscopic picture show erythrophagocytosis with histiocytes proliferation with histiocytes proliferation

► Ulcer may lead to perforation or bleeding if pt Ulcer may lead to perforation or bleeding if pt left untreated or inadequately treated. left untreated or inadequately treated.

► Bowl may perforate several sites including Bowl may perforate several sites including large bowl also. large bowl also.

Clinical Features & Diagnosis Clinical Features & Diagnosis

► The patient present in or has recently visited an The patient present in or has recently visited an endemic areas has persistent high temperature for endemic areas has persistent high temperature for 2 – 3 weeks.2 – 3 weeks.

► The pt may be toxic with abdominal distension from The pt may be toxic with abdominal distension from paralytic ileus. paralytic ileus.

► Pt may have melena due to hemorrhage from Pt may have melena due to hemorrhage from typhoid ulcer, can lead to hypovolemia typhoid ulcer, can lead to hypovolemia

► Positive blood & stool culture confirm the nature of Positive blood & stool culture confirm the nature of infection and exclude malaria. infection and exclude malaria.

► Widal test also used to detect the presence of Widal test also used to detect the presence of agglutinins to O & H antigens of salmonella typhi agglutinins to O & H antigens of salmonella typhi

► After second week signs of peritonitis usually After second week signs of peritonitis usually denote perforation confirmed by presence of free denote perforation confirmed by presence of free gas seen on x-ray. gas seen on x-ray.

Other Test To detect specific & Other Test To detect specific & sensitive marker of typhoid sensitive marker of typhoid

fever fever ► Practical and cheep kits are available for rapid Practical and cheep kits are available for rapid

detection need no special expertise or detection need no special expertise or equipment are equipment are 1- Multi-Test Dip-S-Ticks to detect IgG 1- Multi-Test Dip-S-Ticks to detect IgG 2- Tubex to detect IgM 2- Tubex to detect IgM 3- TyphiDot to detect IgG & IgM 3- TyphiDot to detect IgG & IgM

► These tests are particularly valuable when These tests are particularly valuable when blood culture are negative (due to self blood culture are negative (due to self medication or pre-hospital treatment with medication or pre-hospital treatment with antibiotics). antibiotics).

► These test mostly used when facilities for These test mostly used when facilities for other test not available. other test not available.

Treatment Treatment

►Resuscitate with IV fluid and antibiotics Resuscitate with IV fluid and antibiotics in ICU to stabilize patient condition. in ICU to stabilize patient condition.

►Cephalosporin, metronidazole & Cephalosporin, metronidazole & gentamicin are used in combination. gentamicin are used in combination.

►Despite of potential side effects such as Despite of potential side effects such as aplastic anemia of chloramphenical is aplastic anemia of chloramphenical is still used in developing countries. still used in developing countries.

►Laprotomy then carried out. Laprotomy then carried out.

Surgery Surgery ► Commonest site of perforation is terminal ileum Commonest site of perforation is terminal ileum ► Most appropriate surgical option depend upon general Most appropriate surgical option depend upon general

condition of the patients, the site of perforation, number of condition of the patients, the site of perforation, number of perforation & degree of peritoneal soiling. perforation & degree of peritoneal soiling.

► Closure of perforation after freshening the edges, wedges Closure of perforation after freshening the edges, wedges resection of ulcer area and closure,resection of ulcer area and closure,

► Resection of bowl area with or without anastomosis Resection of bowl area with or without anastomosis ► Closure of perforation and side-to-side anastomosis Closure of perforation and side-to-side anastomosis ► Iliostomy or colostomy where the perforated bowl is Iliostomy or colostomy where the perforated bowl is

exteriorised after refashioning the edges exteriorised after refashioning the edges ► After closing of ilial perforating area, surgeon should also look After closing of ilial perforating area, surgeon should also look

for other sites of perforation or necrotic patches for other sites of perforation or necrotic patches ► Peritoneal lavage is essential, peritoneum should be closed Peritoneal lavage is essential, peritoneum should be closed

and wound should be open for delayed primary or secondary and wound should be open for delayed primary or secondary intention. intention.