Surgery Posting 1

ADEWUMI TOLUWALOPE .E.

Outline
• Introduction
• Aetiology
• Typical parts affected
• Pathogenesis
• Antigen vaccine used in preventing salmonella typhoid
QUESTION
•Brieflydescribe the
aetiopathogenesis of typhoid
perforation
 What is typhoid perforation?
• Typhoid fever is caused by Salmonella typhi (or paratyphi)
bacteria.
• Typhoid perforation is a complication of typhoid fever and
accounts for 40-50% of mortality associated with typhoid fever.
This perforation occurs majorly in the ileum as a breach in the
epithelial lining and between the end of the first week of
infection and third week.
• Perforation of the bowel from typhoid perforation is a serious
abdominal complication which usually leads to diffuse
peritonitis requiring early surgical intervention.
Aetiology
• It
is caused by the Gram negative bacteria organism,
Salmonella typhi and paratyphi.
• It
is a facultative intracellular anaerobe parasite, rod-like,
has a cell wall, motile flagella & polysaccharide capsule
called V1 antigen (a polysaccharide capsule that
surrounds the 0 antigen, thus protecting the bacteria
from antibody attack on the 0 antigen).
• The incubation period is 10-14 days.
 Pathogenesis of typhoid perforation
• Humans are the only reservoir. Transmission is by the faeco–oral
route or via contaminated food and water.
• The bacteria moves down the digestive system in the ingested
contaminated food/water where it then targets epithelial cells and
microfold cells of the small intestine in the distal ileum in close proximity
to the Peyer’s patches, which are important lymphoid tissue in the gut .
• It attaches to the host cell and enters through endocytosis then
employs a type III secretion system to inject proteins into the host cell
altering its cytoskeletal structure and inducing the uptake of the bacterium
into the cytoplasm of the host cell. This serovar’s pathogenicity is more
invasive
Pathogenesis of typhoid perforation
(conti)
• Once it passes through the endothelial cells to the submucosa,
they are taken up by macrophages. The macrophages carry the
bacteria to the reticuloendothelial system where bacteria multiply
intracellularly causing lymphoid hyperplasia and hypertrophy.
• The bacteria reinvades the bowel via the liver and gallbladder
• Reinvasion of the gut especially the Payer’s patches in the distal
ileum results in an immune response of the body typically at the
antimesenteric border of the terminal ileum because of the low
blood supply.
 Aetiopathogenesis of typhoid
perforation
• Thisresults in an inflammatory response and infiltration of
macrophages and T lymphocytes causing tissue/mucosal
damage, alteration and necrosis ---- haemorrhage and
perforation; the loss of GAGs and the vascular changes are
indicative of TNF-α – mediated pathology.
• Theperforation caused results in the leakage of intestinal
contents into the peritonium leading to a full blown peritonitis
>> bloodspread infection(sepsis), N/V, severe abdominal pain
• And the bacteria accesses the lymphatic system which
ultimately leads to more widespread dissemination through
circulation.
• Once in circulation, they can target cells in multiple organ
systems. Most importantly, they infect macrophages in which
they replicate and are able to disseminate throughout the
reticuloendothelial system (splenomegaly, hepatomegaly,
osteomyelitis, meningitis, cardiac involvement, kidney failure)
Typically affected parts
• Payer’s patches
• Mesenteric lymph nodes
• Liver
• Gallbladder
• Spleen
• Bone marrow
• Kidneys
Clinical symptoms
o Fever which starts low and increases daily
o Sudden abdominal pain
o Vomiting
o Headache
o Joint pain
o Anorexia
o Diarrhoea
o Constipation
Management: Examination
• On inspection: • On palpation:
 Toxic ill-looking  Abdominal tenderness
 Obvious abdominal distension  Abdominal guarding
 Sometimes jaundiced  Rebound tenderness
 Pale  Rigidity
 Dehydrated  Loss of hepatic dullness
 Maculopapular rash (rare)
• On auscultation:
 Absent/diminished bowel sound
 Increased heart rate
 Decreased blood pressure

• DRE --- empty rectum

Management: Investigations
• Full blood count: Leucopenia with relative lymphocytosis, anaemia,
thrombocytopenia
• Blood, stool and urine culture --- sensitive in the 1 st, 2nd and 3rd week respectively
• Bone marrow culture ---- most sensitive
• Chest X-ray --- free air under the diaphragm
• E/U/Cr ---- low K+
• Abdominal USS or CT --- free fluid and free air with fine floating echoes in
peritoneal cavity
• Widal test
• Liver function test
Management : Treatment
• Admit the patient
• Perform pre-operative and intraoperative measures:
 Resuscitation with IV fluid (crystalloids, blood if necessary)
 Commence broad spectrum antibiotics in the form of 3rd
generation cephalosporin {ceftriaxone, fluoroquinolone and
metronidazole}
 Nasogastric tube insertion for gastric decompression
 Urethral catheterization to monitor urine output
 Peritoneal lavage with NS through exploratory laparotomy
 Abdominal tube drain after thorough peritoneal lavage
• Surgical intervention is the main stay:
 Simple primary closure --- procedure of choice as it is quick and cost effective
 Wedge excision and closure
 Resection and anastomosis
 Ileostomy

• Post-operativecare {NPO, nasogastric tube removal, daily wound

care} and prevention of postoperative complications such as fecal
fistula, wound infection, surgical site infection, residual abscess,
pneumonia, enterocutaneous fistula, re-perforation, renal failure,
mortality
Vaccine used in preventing typhoid
• This vaccine is made from the capsule of the bacteria
• Thereare two different vaccines are available to prevent
typhoid fever:
 One vaccine is delivered orally and consists of live attenuated
Salmonella serovar Typhi.
 The other vaccine consists of the Vi capsular polysaccharide and
is delivered parenterally.
• Vaccinationis recommended for people who travel from
developed countries to endemic areas including Asia,
Africa, and Latin America.
 Conclusion
• Typhoid perforation remains the most common emergency
surgery performed. The incidence continues to rise, so also the
mortality, despite new antibiotics and improvement in surgical
technique.
• Earlyand appropriate surgical intervention with effective pre-
and post-operative care may improve survival in typhoid ileal
perforation. But the key to survival lies more in the prevention
of typhoid fever by providing safe drinking water and improved
sanitation methods.
•Thank you