Surgical management of perforated bowel due to typhoid infection. What are the predictive factors for pre-operative diagnosis in the endemic area

Abstract

Perforated typhoid fever is a common cause of peritonitis in the endemic areas and associated with high mortality and morbidity if not managed properly. This prospective study included 75 patients with perforated bowel that operated upon in two years ( 2017-2018) and other 29 cases of non-perforated typhoid enteritis presented as acute abdomen. Of 75 cases, 13 (17%) presented as local peritonitis, while 63 (87%) as general peritonitis, which was confirmed by chest X-Ray/ gas under the diaphragm in 80%. 61(81%) patients were males. The age was 15-40 years in 54 (72%) patients. White Blood Cell count [WBC] is low or normal in all cases. 35(46%) patients were presented as an acute abdomen without fever. All patients had at least one perforation in the terminal ileum. There was single perforation in 47(62%) patients. The midline incisions were complicated by dehiscence in 15 (24%) of 54 cases and by wound infection in 35(64%). Six(8%) cases were complicated by fecal fistula and 3(4%) patients unfortunately died. Wound infection complicated 4 (26%) of 15 cases of gridiron incisions, but no wound dehiscence or incisional hernia. WBC is helpful in the diagnosis of perforated bowel due to typhoid infection. This is important for the proper choice of an incision.  Grid iron incision is associated with minimal complications and is preferred to the midline one. Acute diffuse peritonitis indicates perforation in almost all cases, but only one-third of local peritonitis caused by perforation. Early limited surgery and the proper choice of antibiotics according to local microbiologist opinion or culture decreased the mortality to 4%.