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a r t i c l e i n f o
a b s t r a c t
Article history:
Received 27 December 2012
Received in revised form
24 January 2013
Accepted 29 January 2013
Available online 9 February 2013
Background: The management of ileal typhoid perforation is a challenging task in our environment. Lack
of incidence data base and poor nancial resources preclude adequate prevention of this public health
menace.
Objectives: For now the focus will remain the effective and strategic management of this complication to
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
State University of Science and Technology Teaching Hospital (ESUTH). All were resuscitated with 1v
uids, iv antibiotics, nasogastric tube suction and where indicated blood transfusions. Majority had
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 presentation 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.
Keywords:
Management
Ileal perforation
Typhoid
1. Introduction
4Ileal perforation as a complication of typhoid fever and enteritis
has continued to be a major public health problem in the developing
world, because of its persistent high morbidity and mortality.
* Corresponding author. Department of Morbid Anatomy, University of Nigeria
Medical School, Enugu, Nigeria.
E-mail address: martin_nze@yahoo.com (M.A. Nzegwu).
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
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A.I. Ugochukwu et al. / International Journal of Surgery 11 (2013) 218e222
3. Results
Eighty six patients were reviewed for ileal perforation secondary to typhoid fever. Sixty six (76.7%) patients were males and
219
Table 1
Age distribution of patients.
Age (yrs)
Number
Percent
0e9
10e19
20e29
30e39
40e49
50e59
Total
17
33
17
9
7
3
86
19.8%
38.3%
19.8%
10.5%
8.15
3.5%
100%
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220
Table 2
Duration of symptoms prior to admission.
Table 4
Ellcited clinical signs/ndings.
Duration
No. of cases
Percent
Findings
No. of cases
Percent
<1wk
1e2 wks
2e3 wks
3 wke4 wks
5 wks
>6 wks
7
23
31
13
8
4
8.1%
26.7%
36.1%
15.1%
9.3%
4.7%
Abdominal distention
Abdominal rigidity with rebound & absent
bowel sounds
Distended doughy mildly tender abdomen
with ileus
Blood pressure less than 100 mm systolic
Pulse rate >120/min
Rose spots
Disorder of CNS/toxic confusion states
Clinical jaundice
78
61
90.7%
70.9%
23
26.7%
64
77
2
15
7
74.4%
89.4%
2.3%
17.4%
8.1%
Table 3
Clinical symptoms recorded on admission.
Symptom
No. of cases
Percent
Abdominal pain
Nausea and vomiting
Diarrhea
Constipation
Abdominal distension
Fever
Cold sweat
Confusion and agitation
Jaundice
78
61
25
47
65
43
27
15
5
90.7%
70.9%
29.0%
54.7%
75.6%
50.1%
33.4%
17.4%
5.8%
Table 5
Investigations prior to admission or before surgery.
Investigation
Pcv
67.4%
Widal test
White cell count
Blood culture
Stool culture
Erect abdominal X-ray
Abdominal pelvic ultrasound
No. of cases
Percent
77
64
58
76
10
32
58
57
89.5%
74.4%
67.4%
88.4%
11.6%
37.2%
67.4%
66.3%
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A.I. Ugochukwu et al. / International Journal of Surgery 11 (2013) 218e222
Table 6
Duration of perforation prior to operation.
221
Table 8
Number of ileal perforations.
Time
No. of cases
Percent
No. of perforation
No. of cases
Percent
<6 hrs
6e12 hrs
12e24 hrs
24e48 hrs
48e72
72e96
>96 hrs
Total
Mean (hrs)
e
12
17
42
11
3
1
86
36.4
0%
14%
48.8%
48.8%
12.8%
3.5%
1.2%
100%
1
2
3
4
Total
61
15
7
3
86
70.9%
17.4%
8.2%
3.5%
100%
Table 7
Operative ndings.
Table 9
Operative procedures performed and mortality rate for each procedure.
Distance of perforation
from ileo-caecal valve
No. of cases
0e19 cm
20e39
40e59
60e79
80e99 cm
>100 cm
Total
23
38
13
8
4
Nil
86
Percent
Procedure
No. of cases
26.7%
44.2%
15.1%
9.3%
4.7%
0%
100%
52
18
Deaths
6
5
Mortality rate
11.5%
27.7%
7
5
2
1
28.6%
20%
2
16
50.0%
Over mortality 18.6%
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222
Table 10
Operative morbidity in 66 cases of ileal typhoid perforation.
Complications
No. of case
Percent
Persistent peritonitis
Intra abdominal abscess
Wound infection
Dehiscence of abdominal wound
Cardio-pulmonary complications
Enterocutanous stula
Acute hepatic failure
Total
6
7
42
10
3
2
2
66
7%
10.6%
63.6%
15%
4.5%
3%
3%
surgery like resection with anastomosis and limited right hemicolectomy with higher mortality of 25%.Similar ndings are also
reported elsewhere22,23 .The causes of mortality in our series
included peritonitis leading to severe endotoxaemia and multiple
organ failure, in nine patients, faecal stula resulting in uid and
electrolyte disturbances and severe malnutrition in ve5 patients.
Two patients had severe persistent bronchopneumonia with fatal
respiratory failures. All deaths occurred in the early post-operative
period. For those that survived, morbidity rates were equality high
with wound infection topping the list as 63.0%, wound dehiscence
at 15%, residual intra-abdominal abscess at 10.6%, cardiopulmonary
complications at 4.5%, and faecal stula at 3%. Our ndings are
similar to nding elsewhere in West Africa.23 Out of the 70 (81.4%)
patients who survived, 69(98.6%) had one or more morbidities.
These resulted in prolonged hospital stay with the attendant heavy
nancial burden on the patients and families.
5. Conclusion
Typhoid fever remains a serious public health problem in the
developing world with a devastating impact on resources-poor
countries. The high mortality rate is still unacceptable despite
some improvements in the last decade. Ileal typhoid perforation
was almost invariably fatal but with development of newer broad
spectrum antibiotics, safe and modern anaesthesia, surgery is now
routinely used to manage ileal typhoid perforation and offers the
best hope of survival. It seem that for the time being in developing
countries with poor-resources, early and prompt diagnosis, adequate resuscitation and early surgery in patients with typhoid ileal
perforation will keep the mortality low.
Ethical approval
Ethical approval was given by the Enugu state University ethics
committee reference no41/12.
Funding
Personal funds.
Author contribution
Dr Ugochukwu surgeon originator and contributor.
Dr Nzegwu pathologist coordinator and proof reader.
Dr Amu contributing author.
Conicts of interest
None declared.
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