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104 Surgical Complications of Typhoid Fever
Table 17.2: Mechanism of surgical complications of typhoid fever. • Abdominal distention can be observed.

• Diarrhoea or constipation: Diarrhoea may occur in the early stag-
es, but constipation sets in later in the course of the illness.
Ingestion of contaminated food/water
• Passage of blood in the stool may occur, either as frank or altered
blood.
Bacteria in small intestine
week 1 • Jaundice may be a complaint.
• Pain at the site of the abscess or osteomyelitis.
Bacteria passed through Physical Examination
Peyer’s patches into Osteomyelitis
circulation (bacteria These patients are usually very ill; common findings include dehydra-
reaches various organs Abscesses tion, pyrexia, pallor from anaemia (about 50% of children with typhoid
3,5
by this route) perforation have a packed cell volume below 30% ), and wasting,
particularly if the illness has gone on for several weeks.
Jaundice may be present. Shock may also be present, as evidenced
by tachycardia and hypotension (blood pressure <80/60 mm Hg);
Bacteria excreted shock is present in about 75–80% of children with typhoid perforation.
in bile (some pass Invasion of Abdominal/rectal examination
into the gallbladder, galllbladder Cholecystitis There is usually distention, but in a few patients distention may not be
where they multiply wall
and remain) remarkable. Patients presenting late may have demonstrable anterior
abdominal wall oedema. Bowel sounds are diminished or absent in
week 2
Bacteria reach terminal those presenting late.
ileum, invade Peyer’s Generalised tenderness with guarding is present; this finding,
patches, and multiply however, may not be remarkable, especially in patients who perforate
there (at this stage, the under medical treatment. Abdominal rigidity is present in only one-
bacteria are excreted in third of children with typhoid perforation. A dilated and tender
5
the stool) gallbladder may be palpable in the right hypochondrium in patients
with cholecystitis.
There may be fullness in the recto-vesical or recto-uterine pouch,
Necrosis and ulceration of Peyer’s patches occur suggesting a pelvic collection of pus. Blood may be seen on the
examining finger in patients with bleeding.
In osteomyelitis or abscess, the affected site should be thoroughly
week 3 examined.
Respiratory examination
Intestinal Intestinal
perforation bleeding In very ill patients, respiratory function is compromised by chest
infection, which is worsened by the marked abdominal distention.
Crepitations may be heard, sometimes bilaterally, indicating that pneu-
monia has set in and is worsening the child’s condition.
Evaluation/Investigations
Because a majority of the patients present with an acute abdomen, intes-
Clinical Presentation tinal perforation and gallbladder involvement need to be excluded. The
History latter is most important, as cholecystitis may not require urgent surgical
5
Presentation is commonly late; most patients present several weeks intervention. The diagnosis of TIP is often clinical, based on features of
3,7
after onset of symptoms, frequently after several attempts at treatment peritonitis, and investigations are done to support the diagnosis and iden-
with antibiotics or traditional medications. Symptoms may be atypi- tify deficits, as well as to ascertain the fitness of the patient for surgery.
3,8
cal in infants and toddlers younger than 5 years of age. A little less 1. Serum electrolytes, urea, and creatinine: The levels of sodium,
5
than 10% develop intestinal perforation under medical treatment, and potassium, chloride, and bicarbonate are estimated. They are often
symptoms may be masked in these patients. deranged, especially in those presenting late. Hypokalaemia is a
The symptoms include: troublesome problem, and metabolic acidosis may be identified. An
elevated urea level is an indication of the severity of dehydration as
• Fever and general body weakness: These are usually the earli-
est symptoms and always precede abdominal pain (in contrast to well as renal compromise; the latter is more likely if hyperkalaemia is
appendicitis, for which pain precedes fever). Headache frequently also present.
accompanies the fever. 2. Plain radiography:
• Chest and upper abdomen (erect film): Some patients with intes-
5
• Abdominal pain usually begins 2–30 days (median = 9 days) tinal perforation present evidence of air under the diaphragm. This
3
after the onset of fever. The pain is initially vague but gradually is present in about 55% of children with TIP, but may be as high
9
becomes generalised. Although typhoid fever without perforation as 96% in those with typhoid colonic perforation. The extent of
may be associated with some abdominal pain, this is usually not pneumoperitoneum is important as it may be necessary to vent the
severe, and the onset of increasing abdominal pain frequently sig- air to improve respiration and reduce hypoxia. Absence of air under
nifies that an intraabdominal complication is setting in. the diaphragm, however, does not exclude perforation. Pulmonary
consolidation may be present in those with chest infection.