International Journal of Health Sciences & Research ([Link].
org) 93
Vol.2; Issue: 9; December 2012
International Journal of Health Sciences and Research
[Link] ISSN: 2249-9571
Case Report
Gall Bladder Gangrene and Perforation Complicating Typhoid Fever
Budensab AH
1*
, Venkatesh M Annigeri
2
1
Department of Pediatrics, SDM College of Medical Sciences and Hospital, Dharwad, India
2
Department of Pediatric Surgery, SDM College of Medical Sciences and Hospital, Dharwad, India
*
Correspondence Email: [Link]@[Link]
Received: 09/11//2012 Revised: 19/12/2012 Accepted: 26/12/2012
ABSTRACT
Gall bladder gangrene with perforation is an uncommon but dreaded complication. Surgical
complications of typhoid fever more commonly involve the gut and rarely gall bladder. The morbidity
and mortality rates are higher especially if they are not detected and treated in time. We report a case of
gall bladder gangrene with perforation which is a rare complication of typhoid fever.
Key words: Typhoid fever, gall bladder, perforation
INTRODUCTION
Gall bladder gangrene with
perforation is an occasional complication of
typhoid fever. Spontaneous perforation in
calculus cholecystitis is infrequent and even
rarer in the absence of gallstones, but
occasionally occurs following typhoid fever.
[1]
If such conditions are not treated in time,
mortality rates are very high. We report a
case of gall bladder gangrene with
perforation complicating typhoid fever in a
child.
CASE REPORT
9 year old boy presented with 10 day
history of fever and 1 day history of pain
abdomen. Pain was diffuse, continuous and
severe interfering with daily activity. Child
did not pass stool for 3 days but had no
history of vomiting or jaundice or burning
micturation. He was shown to a local doctor
but symptoms did not subside and referred
to our hospital for further management.
On examination he was conscious
well oriented, febrile, tongue was coated
mild pallor. He had tachycardia and normal
BP. There was mild abdominal distention;
tenderness and rigidity were present all over
the abdomen. No mass palpable per
abdomen, bowel sounds absent and other
systems normal.
CBC revealed Hb 12.7gms% TC
10660/cumm platelets 46000/cumm
differential count neutrophils 86%
lymphocytes 12% monocytes 2%
eosinophils 0% basophils 0%.
Peripheral smear revealed normocytic
normochromic erythrocytes, leukocytes
normal with increased neutrophils. Platelets
reduced in number, no immature cells or
parasites seen.
Impression: Neutrophilia with
thrombocytopenia
International Journal of Health Sciences & Research ([Link]) 94
Vol.2; Issue: 9; December 2012
An erect abdomen x ray revealed -
multiple fluid levels on central part of
abdomen, no free air under diaphragm
suggestive of small bowel obstruction.
USG abdomen revealed mildly enlarged
liver with normal echo texture, gall bladder
adequately distended with normal walls, no
calculi, small amount of free fluid present
within peritoneum with impression of mild
hepatomegaly and mild ascites.
Widal test was positive with high
titre S typhi O titre 640 S typhi H titre 640 S
paratyphi A (H) negative S paratyphi B (H)
negative.
Child was diagnosed as typhoid
fever with paralytic ileus in the view of high
endemicity of typhoid fever and x ray
abdomen erect not showing any free gas
under the diaphragm.
Child was treated conservatively but
child did not improve, distention and pain
abdomen persisted with bilious aspirate, it
was decided to undertake a exploratory
laparotomy on 3
rd
day of admission and
revealed small perforation at fundus (Figure
1) and the gall bladder was 50% gangrenous
(Figure 2). Thick pus flakes present in the
peritoneal cavity. The terminal ileum, cecum
and appendix were edematous and inflamed.
Cholecystectomy was done and peritoneal
cavity was washed with plenty of normal
saline and abdomen was closed in layers.
Pain and distention reduced post operatively
and child made a smooth recovery.
Figure 1 - Gall bladder showing perforation at fundus Figure 2-Gall bladder showing perforation and gangrene
DISCUSSION
Typhoid gall bladder perforation
(GBP) is a rare surgical sequel of typhoid
infection and is hardly suspected
preoperatively even in places where typhoid
ileal perforation is rampant
[2,3,4]
due to
common feature of generalized peritonitis.
The occurrence of acalculous typhoid GBP
has been ascribed to the concomitant
presence of intense inflammation,
immunosuppression, and highly virulent
organisms.
[5]
Routine plain radiographs of
abdomen and chest for air under diaphragm
might have delayed intervention without
contributing substantively to diagnosis and
treatment. Sood
[6]
suggested high reliability
of ultrasound in diagnosing GBP, but USG
gallbladder showed distention with normal
walls and no calculi. Cholecystostomy was
not possible in this child because he had had
gangrenous gallbladder involving 50% with
perforation at fundus of the gallbladder. It
was observed that the inflamed tissues at the
gallbladder neck could be easily separated
with blunt dissection and hence
cholecystectomy was done.
International Journal of Health Sciences & Research ([Link]) 95
Vol.2; Issue: 9; December 2012
Many series have reported high
mortality among patients with acute GB.
[7]
The diagnosis of acute cholecystitis in
children with typhoid fever requires high
index of suspicion to prevent the potentially
life threatening complications of perforation
and gangrene. Though management is very
challenging, the outcome was good with
early intervention and cholecystectomy.
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7. Essenhigh DM. Perforation of the
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How to cite this article: Budensab AH, Annigeri VM. Gall bladder gangrene and perforation
complicating typhoid fever. Int J Health Sci Res. 2012;2(9):93-95.
