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CHAPTER 17

Surgical Complications of

Typhoid Fever

Emmanuel A. Ameh
Francis A. Abantanga

Introduction Table 17.1: Age and sex of typhoid perforation and perforation rate in children.
Typhoid fever is a common infection that has continued to be a public Number of typhoid perforations Typhoid perforation rate
1, 2
health problem in many developing countries, particularly in areas (1987-1996) (over 5 years)
with poor sanitation and limited availability of clean, potable water. Age Sex Total Number Total Perforation
The surgical complications of typhoid fever are a cause of significant (years) cases of typhoid number of rate (%)
morbidity and mortality in children in many parts of Africa, particular- Boys Girls (%) cases perforations
ly in sub-Saharan Africa. The management of intestinal perforation, <1 1 — 1 (1.6) 25 1 4.0
3–6
which is the most common surgical complication, has posed a dif-
ficult challenge due to its high morbidity and mortality. A controversy 1–4 1 2 3 (4.7) 120 2 1.7
remains regarding what should be the best and most effective surgical 5–9 25 18 43 (67.2) 194 24 12.4
option for treating these intestinal perforations. 10–12 7 10 17 (26.6) 41 12 29.3
Demographics Total 34 30 64 (100) 380 39 10.3
The World Health Organization (WHO) conservatively puts the annual Source: Adapted with kind permission from Annals of Tropical Paediatrics and International Child
global incidence of typhoid fever at 21 million cases, with 1–4% mor- Health, Liverpool School of Tropical Medicine.
tality. The disease predominantly affects school-age children (5–15
2
years of age), although it does occur in younger children. 2
Children account for more than 50% of all cases of typhoid intestinal
perforation (TIP), which is the commonest severe complication of
typhoid, with a peak age incidence of 5–9 years. Unlike typhoid fever
5
4,7
in adults, which predominantly affects males, boys and girls are
equally affected. 5,6
The overall perforation rate of typhoid in children is about 10%,
but the perforation rate appears to increase with age, reaching a high
of 30% by age 12 years (Table 17.1).
5
Typhoid fever, with or without intestinal perforation, appears to
5,7
occur year round, but with a slightly higher incidence in the rainy
season (Figure 17.1). This is perhaps an indication of the gross defects
in sanitation and lack of safe potable water.
Aetiology/Pathophysiology
Typhoid infection is faeco-oral in nature and is due to faecal con-
tamination of food and water. The infection is caused by the bacteria,
Salmonella typhi (also known as Salmonella enterica serotype typhi),
a gram-negative rod found only in humans, and rarely by Salmonella
paratyphi. The mechanism of transmission and causation of the com-
mon surgical complications is as shown in the flow chart in Figure 17.2.
Surgical Complications
Typhoid fever is a systemic infection involving virtually all organs to
varying degrees. The more common surgical complications include
intestinal perforation; intestinal bleeding; cholecystitis (perforation,
empyema); osteomyelitis; and abscesses. Rare surgical complications Source: Reproduced with kind permission from Annals of Tropical Paediatrics and International
Child Health, Liverpool School of Tropical Medicine.
include pancreatitis, hepatic and splenic abscesses, pleural effusion, Figure 17.1: Seasonal distribution of rainfall (top) and typhoid fever in children,
and orchitis. with and without perforation (bottom).
Therefore, the following procedures are called for (note the
mnemonic BSU):
• Week 1: Take Blood for culture.
• Week 2: Take Stool for culture.
• Week 3: Take Urine for culture.