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TYPHOIDSurgicalComplications
*DR. MANSOOR KHAN
28th Oct, 2009
* Resident Surgical “C”, KTH, Peshawar
TYPHOID
Surgical
Complications
TYPHOID
Surgical
Complications
TYPHOID
Surgical
Complications
TYPHOID
Surgical
Complications
TYPHOID
Surgical
Complications
TYPHOID
Surgical
Complications
TYPHOID
Surgical
Complications
Surgical
Complications
TYPHOID
Surgical
Complications
TYPHOID
Surgical
Complications
TYPHOID
Surgical
Complications
Salmonella a formidable
killer!
Surgical
Complications
TYPHOID
Surgical
Complications
“Potentially fatal, multi-systemic illness caused primarily by
Salmonella typhi and paratyphi”
Typhoid---ancient Greek Typhos, smoke or cloud that was believed to
cause disease or madness
S. typhi, a major human pathogen for thousands of years, thriving in conditions of poor sanitation, crowding, and social chaos
430–426 B.C.
Killed 1/3 of the population of Athens, including their leader
Pericles. The power shifted from Athens to Sparta. 2006 study
detected DNA sequences similar salmonella
Antonius MusaA Roman physician who achieved
fame by treating the emperor Augustus with cold baths when he contracted typhoid
Thomas Willis (1621-1675)
The first description of epidemic Typhoid in 1659
Carl Joseph Eberth (1835-1926)
Discoverer of the typhoid bacillus in 1880
Georges Fernand Isidor Widal (1862-1929)
Demonstrated specific agglutinins in the blood of Typhoid patient in 1896----
“The Widal Reaction”
History of typhoid epidemics
DISTRIBUTION
Infects roughly 21.6 million people each
year
* International Estimate
Ramsden AE, Mota LJ, Münter S, Shorte SL, Holden DW. The SPI-2 type III secretion system restricts motility of Salmonella-containing vacuoles. Cell
Kills 200,000 people each year
* International Estimate
Ramsden AE, Mota LJ, Münter S, Shorte SL, Holden DW. The SPI-2 type III secretion system restricts motility of Salmonella-containing vacuoles. Cell
62% of these occurring in Asia and 35% in
Africa
* International Estimate
* Taylor TE, Strickland GT. Malaria. In: Strickland GT, ed. Hunter’s Tropical Medicine and Emerging Infectious Diseases. 8th ed. Philadelphia: WB Saunders, 2000:614-43.
Highest in Pakistan & India in Asian countries
(451.7 per 100,000)
* WHO Estimate
* Bull World Health Organ vol.86 no.4 Genebra Apr. 2008
S
P
R
E
A
D
TY
PH
OID
BL
AC
K H
AN
D
Best prevention Scrub of them off your handsBest prevention Scrub them off your hands
Bacteria are better scientists than we are
War of survival—they are
working out very hard
RISK FACTORS
S. typhi are able to survive a stomach pH as low as 1.5.
Antacids, (H2 blockers), PPI’s, gastrectomy, facilitate
S typhi infection
TYPHOID FEVER RISK FACTORS
Contaminated food,House hold with Cases,
Inadequate hand washing, , drinking unpurified water, and living without a toilet
TYPHOID FEVER RISK FACTORS
Environmental/behavioral risk factors
PRESENTATION
Incubation period
is 7-14 days
FIRST WEEK TEMPERATURE PATTERN
Diffuse abdominal pain, Inflamed Peyer patches narrow the
lumen--Constipation. Dry cough, dull frontal
headache, delirium, increasingly Stupor &
malaise
FIRST WEEK OTHER SYMPTOMS
Rose spots, blanching, truncal,
maculopapules usually 1-4 cm wide, < 5 in
number; these generally resolve within 2-5 days
(bacterial emboli to the dermis)
FIRST WEEK OTHER SYMPTOMS
Distended abdomen, Soft splenomegaly, Relative bradycardia & dicrotic pulse
(double beat, the second beat weaker than the first)
SE
CO
ND
WE
EK
Patient may descend into the typhoid state---apathy,
confusion, and even psychosis
THIRD WEEK TYPHOID STATE
Necrotic Peyer patches, bowel perforation,
Peritonitis, intestinal hemorrhage
may cause death
THIRD WEEK Week of complications
Fever, mental state, and abdominal distension slowly
improve over a few days, complications may still occur
in surviving untreated individuals
FOURTH WEEK WEEK OF CONVALESCENCE
COMPLICATIONS
Immunity, antacids, vaccination,
previous exposure, virulence,
inoculum, choice of antibiotics
GE
NE
RA
L C
OM
PL
ICA
TIO
NS
Bilateral Salmonella typhi breast abscess
unmarried 35-year-old female without any predisposing conditions
Singh S, Pandya Y, Rathod J, Trivedi S. Bilateral breast abscess: A rare complication of enteric fever. Indian J Med Microbiol [serial online] 2009 [cited 2009 Oct 16];27:69-70. Available from: http://www.ijmm.org/text.asp?2009/27/1/69/45176
ME
DIC
AL
CO
MP
LIC
AT
ION
S
MAJOR SURGICAL COMPLICATIONS
MA
JOR
SU
RG
ICA
L C
OM
PL
ICA
TIO
NS
Morbidity 55.4%mortality 28.5 %
INTESTINAL PERFORATIONS
5% of people with typhoid fever experience this complication
DS00538 April 10, 2008© 1998-2009 Mayo Foundation for Medical Education and Research (MFMER).
Typhoid enteric perforation, Dr Y. Akgun *, B. Bac, S. Boylu, N. Aban, I. Tacyildiz, British Journal of Surgery Volume 82 Issue 11, Pages 1512 - 1515Published Online: 8 Dec 2005
Ileum especially distal ileum, jejunum usually does not perforate in typhoid,usually happens in the third week
MECHANISM OF INTESTINAL PERFORATION
Intestinal peyer’s patches
2 or 3 weeks hx of disease, with suddenly worsening
of pain & general conditions,
Tenderness starts in his right lower quadrant, spreads and eventually becomes generalized, Guarding ,
(seldom the board-like rigidity)
Erect film, shows gas Under diaphragm (50% positive)lateral decubitus film, shows gas
under his abdominal wall
PR
ES
EN
TA
TIN
PE
RF
OR
AT
ION
The bradycardia and leucopenia of typhoid may occasionally mask the tachycardia and leucocytosis
of peritonitis
PA
TIE
NT
PE
RF
OR
AT
ION
If peritonitis seems to be localized, signs confined to only part abdomen, general
condition is good, patient not deteriorating, consider non-operative
treatment.
CONSERVATIVE SURGICALVS
If signs of generalized peritonitis, do a laparotomy
“Suck and drip”
Resuscitation, antibiotics, pass a NG-tube, Monitor abdominal tenderness, pulse,
temperature, white blood count.
If any of these rise, suspect that peritonitis is extending, so take an erect
X-ray film of his abdomen
CONSERVATIVE MANAGEMENT
MDR-area
MDR+NAR-area
MEDICATION TREATMENT WHO RECOMMENDATIONS
Do not forget to cover anaerobes and gram negative bacteria along
with salmonella
Operate as early as possible,
Do as much as necessory & as little as possible
SURGICAL MANAGEMENT
PREPARATIONAdequately resuscitate,
Maintain good urine output, passnasogastric tube down,
Start chemotherapy.
*Agbakwuru EA, Adesunkanmi AR, Fadiora SO, Olayinka OS, Aderonmu AO, Ogundoyin OO et alA review of typhoid perforation in a rural African hospital. West African Journal of Medicine 2003; 22(1):22-25. (13 kb) Abstract only
Su
rger
yS
tep
s
Su
rger
yS
tep
s
S
urg
ery
Ste
ps
S
urg
ery
Ste
ps
S
urg
ery
Ste
ps
CLOSE THE ABDOMEN
Completely
Without drains
Drains are counter productive
POSTOPERATIVELY
Fever usually subsides in 4 or 5 days
Nourish patient as early as possible
ICU care and monitoring
Continue chemotherapy 14days
S
P
E
C
I
M
E
N
S
John Hunter
(1728-1793)
INTESTINAL HEMORRHAGE
Occurs in 10-20
per cent of the cases
Intestinal bleeding is often marked by a sudden drop in blood
pressure and shock, followed by the appearance of blood in stoolH
emo
rrh
age
pre
sen
tati
on
replace the blood loses. Bleeding usually stops
spontaneously
Only operate if bleeding is persistent, or alarmingly
INTESTINAL HEMORRHAGE
Surgery Intestinal Hemorrhage
TYPHOID CHOLECYSTITIS
Occurs in 1-2% of cases
*According to Indian study 8%
More common in children
Antibiotic resistance & virulence of bacteria
*M.L. Kulkarni, SJ. Rego, Department of Pediatrics, J.J.M. Medical College, Davangere 577 004.
Acute Acalculous CholecystitisTYPHOID
Acute Acalculous CholecystitisTYPHOID
*Thickened gall bladder wall, sonographic Murphy's sign,
pericholicystic collection in the absence of gall stones
*Subha Rao SD, LewinS, Shetty B, et al. Acute acalculous cholecystitis in typhoid fever. Indian Pediatr 1992, 29: 1431-1435.
Acute Acalculous CholecystitisTYPHOID
Unlike other AACs, antibiotic therapy is the
recommended treatment for Typhoid AAC
Chronic Cholecystitis (Carriers)TYPHOID
Excretes bacteria in stools
for more > 1 year1-4% of
non-treated infected patients
become chronic carriers
Patients with cholelithiasis, biliary anomalies, females,
Salmonella can be cultured
from stools, duodenal
aspirate, gall stones
Mary Mallon (September 23, 1869 – November 11, 1938)
Forcibly quarantined twice, she infected 47 people,
three of whom died. She died in quarantine.
Chronic CholecystitisTYPHOID
Biliary anomalies, stones--requires
cholecystectomy + antibiotics
4-6 weeks antibiotic treatment
MA
JOR
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ICA
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OM
PL
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MA
JOR
SU
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ICA
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OM
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Typhoid Enteric Perforation: Prognostic Factors an Experience with 76 PatientsJ Ayub Med Coll AbottabadJan - Mar 2000;12(1):49-52.Department of Surgery, Khyber Teaching hospital, Peshawar
Arkadiy Stavrovskiy, Typhoid. 1932Oil on canvas
OIL ON CANVAS
Ty21a—Oral live attenuated vaccine
Vi-CPS— parenteral vaccine
TYPHOID
Surgical
Complications
TYPHOID
Surgical
Complications
TYPHOID
Surgical
Complications
TYPHOID
Surgical
Complications
TYPHOID
Surgical
Complications
TYPHOID
Surgical
Complications
TYPHOID
Surgical
Complications
Surgical
Complications
TYPHOID
Surgical
Complications
TYPHOID
Surgical
Complications
TYPHOID
Surgical
ComplicationsSurgical
Complications
TYPHOID
Surgical
Complications
Good food handling & water sewage treatment can eliminate typhoid
Prompt anntibiotic
therapy can save many
lives—take it a serious job
Severe vomiting,
diarrhoea & abdominal
distension--- complicated,
admit them & give IV
antibiotics and support
Prognosis of complications
depends on the time-lapse
b/w onset & treatment
take home messagekiller
salmonellaformidable
w
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