Pathology and management of typhoid perforation.pptx

PPT

1. TYPHOID PERFORATION

2. OUTLINE Introduction Epidemiology Aetiopathogenesis of typhoid perforation Clinical presentation Investigations Treatment Resuscitation Definitive Treatment Prognosis References

3. INTRODUCTION Typhoid fever is an acute systemic infection with a protracted course. Caused by ingestion of the bacteria salmonella typhi in contaminated food/water, which invades the bowel through peyer’s patches It has remain a public health problem in the developing countries with gut perforation been the major complication ( accounting for 40-50% of deaths).

4. EPIDEMIOLOGY It is a global problem, occurs more in developing countries due lack of safe drinking water and good sewage treatment/disposal system 13-17million cases worldwide 600,000 deaths annually Commoner between age 5 and 40yrs

5. AETIOPATHOGENESIS Of TYPHOID PERFORATION Following ingestion of food/water contaminated by feces of and individual infected with Salmonella typi , rarely paratyphi A, B & C I nfective dose is 10 3 -10 6 colony-forming units is large enough to bypass gastric defense system The organism reaches the small intestine and passes through the peyer’s patches sensitizing the lymphoid tissue in the process The organism multiply in the mesenteric lymph nodes and enter the circulation through the cysterna chyle and thoracic duct causing an initial bacteraemia .

6. AETIOPATHOGENESIS Of TYPHOID PERFORATION RE especially kupfer cells of the liver mopps up organisms in circulation Multiplication the RE cells causes necrosis of the cells with release of large number of organisms into circulation giving rise to septicemia phase during which the patient is very sick and toxic on account of systemic infection The organisms are also released into the bile through which they reach the intestine

7. AETIOPATHOGENESIS Of TYPHOID PERFORATION Re-enters the previously sensitized peyer’s patches and a hypersensitivity occurs with swelling of the peyer’s patches and congestion of the subjacent mucosa and muscle layer. Obstruction of blood supply to peyer’s patches leads to necrosis and development of shallow, irregularly oval ulcers arranged longitudinally on the antimesenteric border of the ileum, especially the terminal ileum.

8. AETIOPATHOGENESIS Of TYPHOID PERFORATION Separation of the slough may lead to severe hemorrhage of perforation of the bowel wall In about 15% of patients, there may be 2 perforations and in 5% more than 2 perforations. The perforations are mostly in the ileum and most (90%) within 60cm from the ileocaecal junction.

9. AETIOPATHOGENESIS Of TYPHOID PERFORATION Rarely ( 2 %) there may be perforation of the caecum or ascending colon. With perforation, ileal contents (digested food- chyme , GI secretions, GI bacteria esp E.coli & Bacteroides ) leak into the peritoneal cavity causing generalized peritonitis Without intervention this will progress to shock(septic or hypovolemic ), MODs and death

10. CLINICAL FEATURES This classically occurs in the 3rd week of illness. Most patients are between 5 and 40 years and only 5% are over 40 years The presentation may be sudden or insidious more commonly.

11. CLINICAL FEATURES Symptoms : Preceding hx of Fever, Abdominal pain, myalgia, arthralgia, Diarrhia or constipation, loss of appetite +/- vomiting With perforation: Abd pain, initially in the RIF, progressively becomes generalized, High grade fever, vomiting, constipation +/- abd distension, generalized body weakness Signs: Acutely ill looking, febrile, maybe pale, anicteric, dehydrated

12. CLINICAL FEATURES Abdomen Maybe full or distended Generalized tenderness G uarding and rigidity, loss of liver dullness distension, tachycardia and hypotension. CVS: Tarchycadia Hypotension Chest: Tarcypnea

13. INVESTIGATIONS Chest and Plain abdominal X-ray Erect Shows free air under the diaphragm in 75% of cases Ground glass appearance in peritoneal fluid collection Abdominopelvic USS: Free fluid collection in the peritoneal cavity Culture: Blood, stool and urine Serial widal test PCR

14. INVESTIGATIONS FBC + Differential, GXM U/E/Cr

15. TREATMENT Resuscitation Correct dehydration with IVF N/S or Ringers lactate Pass urethral catheter to monitor the adequacy of resuscitation Pass NG tube to decompress the stomach Correct anemia Correct hypoglcyaemia Broad spectrum empirical antibiotics to cover Gramm positive, Gramm negative and anaerobic organisms Counsel patient and obtain informed consent for emergency surgery Booking and Anaesthesia review

16. TREATMENT Definitive treatment is surgery Type of surgery depends on: Patients clinical state Degree of contamination seen intra op Site of perforation

17. SURGICAL OPTIONS Simple closure of perforation Wedge resection and anastomosis Segmental ileal resection and anastomosis Ileostomy/colostomy Right hemicolectomy with ileotransverse anastomosis Laparoscopic surgery

18. PROGNOSIS In those treated operatively, mortality is about 15% if presentation is within 24hrs of perforation, prognosis worsen with late presentation

19. CONCLUSION Prevention of Typhoid fever is the main stay of preventing its complications. However when they occur like gut perforation, prompt diagnosis, adequate peri-op care, immediate surgical intervention will ensure reduction of morbidity and mortality to bearest minimum

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