What findings should be assessed during a systematic per‑abdominal examination in a patient with suspected or confirmed typhoid fever?

Per Abdomen Examination in Typhoid Fever

Critical Initial Assessment

In a patient with suspected or confirmed typhoid fever, systematically assess for abdominal pain, tenderness (especially right lower quadrant), hepatosplenomegaly, and signs of peritonitis, as these findings directly impact mortality risk and guide urgent surgical intervention. 1

Key Clinical Findings to Assess

Palpation for Organomegaly:

• Splenomegaly is present in 100% of confirmed typhoid cases and is the most consistent finding on physical examination 2, 3
• Hepatomegaly occurs in approximately 31-45% of patients and typically presents with normal consistency 2, 4
• Both findings typically emerge within the first week of illness 2, 3

Abdominal Tenderness and Pain:

• Diffuse abdominal pain is a common presenting symptom, reported in 43-57% of cases 5, 6
• Right lower quadrant tenderness or peritoneal signs indicate potential ileal perforation—a life-threatening complication with mortality up to 60% 1, 7
• Perforation typically occurs in the third week of disease but can present anywhere from 24 hours to 16 days after symptom onset 1

Signs of Peritonitis (Surgical Emergency):

• Assess for rebound tenderness, guarding, and rigidity 1, 7
• The presence of peritoneal signs mandates immediate surgical consultation, as surgery is the definitive treatment (Recommendation 1B) 7
• Free fluid in the abdomen (ascites) occurs in only 3.4-9% of cases but when present suggests perforation with peritoneal contamination 2, 4

Systematic Examination Sequence

Inspection:

• Look for abdominal distension suggesting bowel perforation or significant ascites 1, 7
• Rose spots (salmon-colored macules on trunk) are classically described but frequently absent 5

Palpation:

• Begin with gentle palpation in all four quadrants to identify areas of maximal tenderness 1
• Specifically palpate the right lower quadrant (terminal ileum location) where perforation most commonly occurs 1
• Assess liver span and splenic enlargement systematically 2, 3
• Evaluate for mesenteric lymphadenopathy, though this is better detected by imaging 3, 4

Percussion:

• Assess for shifting dullness if ascites is suspected 2
• Evaluate liver and spleen size 2, 3

Auscultation:

• Listen for bowel sounds; absent or diminished sounds suggest ileus or perforation 1, 7

Critical Red Flags Requiring Urgent Intervention

Immediate Surgical Consultation Indicators:

• Peritoneal signs (rebound, guarding, rigidity) 1, 7
• Signs of septic shock: systolic BP <90 mmHg, decreased capillary refill, skin mottling, peripheral cyanosis 7
• Sudden worsening of abdominal pain after initial improvement 1, 7

These findings indicate typhoid intestinal perforation with mortality rates of 15-60% depending on timing of intervention 7

Complementary Diagnostic Approach

While physical examination is essential, ultrasound should be performed in the initial evaluation, especially in resource-limited settings, with 90% sensitivity and specificity for detecting complications 1. Key ultrasound findings that correlate with physical examination include:

• Splenomegaly (100% of cases) 2, 3
• Bowel wall thickening, particularly terminal ileum (85%) 3, 4
• Mesenteric lymphadenopathy (43-77%) 2, 3, 4
• Free fluid suggesting perforation 7, 2

Common Pitfalls to Avoid

• Do not dismiss mild abdominal tenderness in a febrile patient with travel history to endemic areas; perforation can develop rapidly 1
• Do not wait for classic findings (rose spots, relative bradycardia, stepwise fever) as these are frequently absent 5, 6
• Do not delay surgical consultation when peritoneal signs are present; mortality increases dramatically with delays beyond 24 hours 7
• Consider typhoid fever in any febrile patient with diarrhea or abdominal pain who has traveled to South/Southeast Asia, Africa, or Latin America 1, 6