Typhoid Intestinal Perforation: 24 Perforations in One Patient
A 35-year-old male patient was admitted in surgery out-patient department with complains of fever for 2 weeks, abdominal pain and vomiting for 4 days, abdominal distension for 2 days, and constipation for 2 days. He did not receive any treatment during 2 weeks. There was no history of chronic abdominal pain or analgesic abuse, but patient was a smoker and alcoholic. There was no any history suggestive of previous typhoid infection. On physical examination, abdomen was tense, tender, and distended with absent bowel sound. Both guarding and rigidity were present all over the abdomen. On digital rectal examination, there was empty rectum. An upright abdominal radiograph showed free gas under both domes of diaphragm. Laboratory examinations gave the following results: Hematocrit 30%, white blood cell count 14500/cm3, platelets 268 000/cm3, sodium 138 mEq/L, potassium 3.2 mEq/L, blood urea 32 mg/dl, S. Creatinine 1.6 mg/dl, blood glucose 110 mg/dl, and total bilirubin of 2.5 mg/dl. Diagnostic test for hepatitis B, hepatitis C and HIV were negative. The patient was Widal positive (Titer of > 1:160). An abdominal ultrasound showed features consistent with intestinal perforation showing both free fluid and free air with fine floating echoes in peritoneal cavity. However, blood culture was negative for Salmonella typhi in the patient. No bile culture was performed pre-operatively. Hence, the diagnosis of acute peritonitis due to intestinal perforation was made pre-operatively.\nThe patient was resuscitated with intravenous fluid and commenced on antibiotics ceftriaxone and metronidazole pre-operatively. Nasogastric tube insertion for decompression and urethral catheterization was carried out for monitoring urine output. Exploratory laparotomy was performed through midline incision and fecal peritonitis with exudative flakes all over the intestine was found. Thorough peritoneal lavage was carried out with normal saline. There were 24 perforations (21 in terminal ileum and 3 in cecum) present in distal 35-40 cm of terminal ileum reaching up to ileocecal junction and the Cecum on anti-mesenteric border as shown in Figures and . Resection of the perforated intestinal segment with ileo-transverse anastomosis (side-to-side) with proximal loop ileostomy was performed. Abdominal tube drain Fr. 30 was put in pelvis after thorough peritoneal lavage using the normal saline and abdomen was closed in layers. Patient was kept on i.v. fluids and nil orally for 3 days. Broad spectrum antibiotic in the form of 3rd generation cephalosporin with metronidazole and fluoroquinolone were given for 7 days. Nasogastric tube and abdominal drain tube were removed on 3rd post -operative day (POD). Ileostomy started functioning on 4th POD. Patient was discharged on 7th POD with oral fluoroquinolone for 7 days. Histopathological examination revealed evidence of severe acute inflammation, with fibrinopurulent exudates extending along the serosal surface of intestine and acute and chronic inflammation was observed immediately adjacent to the site of perforation. Evidence of villous blunting and elongation of the crypts was observed, which suggests chronic mucosal injury. We were unable to isolate S. typhi from resected bowel specimen; however, stool culture was positive for S. typhi. We were unable to perform Polymerase chain reaction for isolation of S. typhi and other serotypes responsible for TIP due to scarcity of resources at our center. These findings are consistent with TIP. On the basis of these findings, the diagnosis of typhoid enteric perforation was confirmed. Patient came regularly for follow-up, gained weight, and managed ileostomy properly. We closed ileostomy after 12 weeks.