Typhoid Fever: Constipation and Associated Symptoms
In typhoid fever patients presenting with constipation, fever is the most consistently associated symptom, occurring in 97-100% of cases, followed by abdominal pain as the second most common associated feature. 1
Primary Clinical Presentation Pattern
The classic symptom constellation in typhoid fever includes:
- Fever: Present in virtually all cases (97-100%), characterized by sustained, high-grade fever with insidious onset over 3-7 days 1
- Abdominal pain: The second most common symptom, occurring alongside constipation in the majority of patients 2, 3, 4, 5
- Constipation or diarrhea: While diarrhea is uncommon in typhoid fever (occurring in a minority of cases), constipation is a recognized gastrointestinal manifestation 2
Important Clinical Context
Typhoid fever is fundamentally a bacteremic illness where gastrointestinal symptoms are not the predominant feature. 2 The disease is characterized by fever associated with headache, lethargy, malaise, and abdominal pain, followed by hepatosplenomegaly and stupor, with diarrhea being an uncommon feature. 2
When constipation is present in typhoid fever, the clinical picture typically includes:
- Prolonged febrile illness: Fever persisting for days to weeks before other complications develop 2, 6
- Systemic manifestations: Headache, lethargy, malaise accompanying the fever and abdominal symptoms 2
- Abdominal tenderness: Diffuse abdominal pain and tenderness on examination 4, 5
Critical Complications to Monitor
When a patient with typhoid fever presents with constipation and abdominal pain, intestinal perforation must be considered, as it occurs in 10-15% of cases and carries mortality rates of 4.6-39%. 1, 6 Perforation typically occurs in the third week of disease but can occur as early as 24 hours. 2, 6
Warning signs that suggest progression to perforation include:
- Acute worsening of abdominal pain with signs of peritonitis 2, 6
- Markedly elevated leukocyte count (e.g., >20,000), which strongly suggests perforation with peritonitis 1
- Free fluid in the pouch of Douglas on imaging, indicating peritoneal contamination 6
- Signs of septic shock: Hypotension, tissue hypoperfusion, decreased capillary refill 6
Diagnostic Approach
Blood culture remains the gold standard for diagnosis, with highest yield in the first week of symptoms (sensitivity 40-80%), and should be performed in all patients with suspected enteric fever. 1 The diagnosis should be considered when a febrile person (with or without diarrhea) has a history of travel to endemic areas or consumed foods prepared by people with recent endemic exposure. 2