From the Guidelines
Intestinal perforation in typhoid fever occurs when the bacteria Salmonella Typhi causes severe inflammation and ulceration of the Peyer's patches in the small intestine, particularly in the terminal ileum, leading to a high morbidity and mortality rate, especially in low-income countries 1. The pathogenesis of intestinal perforation in typhoid fever involves the invasion and multiplication of Salmonella Typhi within intestinal lymphoid tissue, triggering an inflammatory response that damages the intestinal mucosa 1.
Key Factors Contributing to Perforation
- Delayed treatment
- Virulent bacterial strains
- Poor nutritional status
During the third week of illness, these ulcers can deepen and erode through the entire intestinal wall, creating a hole that allows intestinal contents to leak into the peritoneal cavity 1. The necrosis of lymphoid tissue progresses until the ulcers penetrate all layers of the bowel wall. Patients typically present with sudden severe abdominal pain, rigid abdomen, and signs of peritonitis 1.
Clinical Presentation and Management
- Abdominal pain and fever are the most common clinical presentations
- Perforation typically occurs in the third week of disease
- Surgery is recommended in case of typhoid intestinal perforation, with simple excision and closure of small perforations being reported in up to 88.2% of cases 1
- Appropriate antibiotic therapy, usually with third-generation cephalosporins, fluoroquinolones, or azithromycin, is also necessary, depending on local resistance patterns 1.
The high morbidity and mortality rates associated with intestinal typhoid perforation, ranging from 4.6% to 39% 1, emphasize the need for prompt diagnosis and treatment to improve outcomes. Immediate surgical intervention and appropriate antibiotic therapy are crucial in managing this life-threatening complication 1.
From the Research
Intestinal Perforation in Typhoid Fever
Intestinal perforation is a serious complication of typhoid fever, which can lead to high morbidity and mortality if not treated promptly and effectively. The following are some key points related to intestinal perforation in typhoid fever:
- Intestinal perforation resulting from Salmonella typhi is an important health problem, particularly in developing countries 2, 3, 4.
- The most common symptoms of intestinal perforation in typhoid fever are fever, abdominal pain, diarrhea or constipation 2, 3.
- Surgical intervention is usually necessary to treat intestinal perforation in typhoid fever, with simple closure and irrigation being a common approach 5, 4, 6.
- Different types of surgical interventions have been employed, including simple bowel closure, bowel resection, and intestinal resection, with varying outcomes 3, 4.
- Early and appropriate surgical intervention, along with effective preoperative and postoperative care, can improve survival in patients with intestinal perforation in typhoid fever 2, 3, 6.
- Factors such as prolonged preoperative period, extended peritoneal contamination, and ileostomy procedure can influence the increase in mortality 3.
- The overall mortality rate for intestinal perforation in typhoid fever can range from 11.0% to 12.8%, with males having a significantly lower mortality rate compared to females in some studies 3, 4.
Surgical Interventions
Some common surgical interventions for intestinal perforation in typhoid fever include:
- Simple bowel closure: This is the most common surgical intervention performed, with a significantly lower mortality rate compared to bowel resection 4.
- Bowel resection: This involves the removal of the affected segment of bowel and can be performed with or without primary anastomosis 3, 6.
- Intestinal resection: This involves the removal of a portion of the intestine and can be performed with or without ileostomy 3, 4.
- Debridement with primary closure: This involves the removal of dead tissue and closure of the perforation site 3.
Outcome and Prognosis
The outcome and prognosis of intestinal perforation in typhoid fever depend on various factors, including: