To review presentation, evaluation and surgical management of typhoid ileal perforation.
Patients and Methods
This retrospective descriptive study was carried out at surgical unit-II, Chandka Medical College Hospital, Larkana from July 1, 2006 to June 30, 2007. Records of 60 patients diagnosed clinically and /or histologically as typhoid ileal perforation were reviewed whereas incomplete records were excluded from the study. After the initial phase of resuscitation, laparotomy was performed in all patients. The degree of contamination, number and site of perforation were noted which affected the decision of dealing with perforation. Patient having single perforation with minimal contamination were chosen for primary repair of perforation, while those having moderate to severe degree of contamination were operated either through exteriorization of perforation or repair with covering ileostomy.
Out of 60 patindent, 44 were males and 16 were female. Median age was 23.12 years (13-55), mean length of pre-presentation illness was 8.8 days, whereas mean length of stay was 9.8 days. Abdominal pain was seen in 60 (100 %) patients, fever in 58 (96.6 %) and signs of peritonitis in 58 (96.6 %) at presentation. Mean TLC was 8450 (range1600-19800). X-ray abdomen revealed pneumoperitonium in 58 (96.6%). Free fluid in abdominal cavity with variable degree of contamination was found in all cases. Most had single perforation (n=50, 83.3%) on anti-mesentric border of ileum followed by two perforations (N=4, 6.66%) and multiple perforations (n=6, 10%) at mean distance of 27.41 cm from ileocaecal valve. Primary closure with or without covering ileostomy (n=28, 46.66%), exteriorization of perforation as ileostomy (n=22, 36.66%), and resection and anastomosis (n=8, 13.3 %) were common surgical procedures performed. Skin was closed in 36 patients (60%), and not closed in 24 (40%). Post operatively wound infection (n=30, 50%), wound dehiscence (n=4, 13.3%) anastomotic leakage (n=4, 6.6%), fecal fistula (n=4, 6.6%), and intra abdomen abscess (n=2, 3.3%) were the common complications seen. Mortality was 13.33% (n=8). Major contributory factors were presence of co-morbids, multiple perforations, long pre-presentation illness, severe sepsis and pre-operative hypovolemia.
Although the incidence of post typhoid ileal perforation with all its dreadful complications has decreased after the introduction of quinolones, it still possesâ€™ major threat for a surgical setup. Early diagnosis and prompt surgical intervention, positively relate with the outcome: more delayed the intervention, more are the complications and worse is the outcome. We found that thorough peritoneal lavage, provision of covering stoma and generous use of broad spectrum antibiotics directly affected the postoperative recovery. (Rawal Med J 2011;36:22-25).
Typhoid ileal perforation, peritonitis, pneumoperitoneum.