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

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Surgical

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TYPHOID

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TYPHOID

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TYPHOID

Surgical

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Salmonella a formidable

killer!

Surgical

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TYPHOID

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“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

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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)

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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

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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

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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

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The bradycardia and leucopenia of typhoid may occasionally mask the tachycardia and leucocytosis

of peritonitis

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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

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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

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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

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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

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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

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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

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