What is the management approach for a patient with typhoid fever presenting with acute abdomen?

Management of Typhoid Fever Presenting with Acute Abdomen

Surgical intervention is required for typhoid fever patients presenting with acute abdomen due to intestinal perforation, with simple excision and closure of small perforations being the most common approach (88.2% of cases). 1

Diagnosis

• Typhoid fever is the most common cause of gastrointestinal perforations in low-income countries, with high morbidity and mortality rates (4.6% to 39%) 1
• The typical clinical presentation includes abdominal pain and fever, with perforation usually occurring in the third week of disease (range 24 hours to 16 days) 1
• Perforations most commonly occur in the ileum or jejunum, and less frequently in the colon and gallbladder 1
• Preoperative diagnosis is usually based on findings of peritonitis in a patient with a history of prolonged febrile illness 1
• Contrast-enhanced CT scan is the most reliable diagnostic exam for intra-abdominal disease when available 1
• Blood cultures should be obtained, though they may not always be positive 2

Management Algorithm

Initial Assessment and Stabilization

• Aggressive fluid resuscitation and correction of electrolyte abnormalities 2
• Broad-spectrum antibiotic therapy should be initiated immediately 1, 2
  • Fluoroquinolones, cephalosporins, and azithromycin are antibiotics of choice, though resistance is increasingly common 2
  • For severe cases, consider IV meropenem, which has shown effectiveness in cases of typhoid fever with liver failure 3

Surgical Management

• Surgery is recommended for typhoid intestinal perforation 1
• Surgical options include:
  1. Simple excision and closure of small perforations (most common approach) 1
  2. Resection and primary anastomosis 1
  3. Limited right hemicolectomy 1
  4. Stoma creation 1
• A damage control approach should be adopted in severely sick patients with physiological derangement 1

Special Considerations

• Be vigilant for coinfection with tuberculosis, which can complicate management and worsen outcomes 4
• Hepatitis and cholestasis can occur with typhoid fever, and in rare cases, may progress to acute liver failure requiring intensive care 3
• Monitor for complications such as intestinal hemorrhage, septic shock, and acute respiratory distress syndrome 5
• In severe cases with systemic toxicity, early surgical consultation is crucial 2

Postoperative Care

• Continue appropriate antibiotic therapy based on culture and sensitivity results 4, 2
• Monitor closely for complications such as wound infection, anastomotic leak, or secondary sepsis 2
• Provide nutritional support during recovery 1

Pitfalls and Caveats

• Delayed diagnosis and treatment significantly increase mortality rates 1
• Multidrug-resistant and extensively drug-resistant typhoid strains are increasingly common, potentially causing delays in effective antibiotic therapy 3
• The presence of comorbidities, especially immunodeficiency, can worsen outcomes 4
• Coinfection with tuberculosis may be missed, leading to inappropriate management and poor outcomes 4
• High-dose dexamethasone has been reported as adjunctive therapy in severe cases with septic shock, but controlled studies in children are lacking 5