Overview of Typhoid Fever
Perforation of enteric typhoid fever is one of the serious complications of typhoid fever, mostly seen in typhoid fever epidemic season and region. Since international attention has been paid to controlling the epidemic of typhoid fever, preventive vaccination and effective drug treatment, the incidence of enteric typhoid fever has decreased significantly, as well as in our country, but there are still sporadic occurrence of patients.
Pathogenesis
Typhoid fever is caused by Salmonella typhi, which enters the intestinal tract through the mouth and invades the lymphoid follicles and lymph nodes in the terminal ileum 100cm away from the ileocecal part, causing inflammatory edema. Bacterial decomposition after bacterial multiplication produces endotoxin that enters the bloodstream through the lymph and causes systemic symptoms. In the second week after the onset of the disease, the lymph nodes on the intestinal wall begin to undergo necrosis, and the necrotic tissues are detached to form ulcers, which are mostly located on the opposite side of the mesentery of the intestinal tubes, and when the pressure in the intestinal lumen increases, it can cause acute perforation. In individual cases, perforation can occur in the jejunum, appendix, cecum and other places. Erosion of blood vessels by ulcers can also cause intestinal bleeding.
Symptoms
Patients tend to start with persistent high fever, abdominal pain, constipation or diarrhea, hepatosplenomegaly, low white blood cell count and relatively slow pulse rate. Patients may have sudden onset of pain in the right lower abdomen, which then spreads throughout the abdomen, accompanied by vomiting and abdominal distension. Examination reveals signs of acute peritonitis, with muscle tension and tenderness throughout the abdomen, evident in the right lower abdomen, and free pneumoperitoneum, narrowing of the hepatic turbidities, loss of bowel sounds, and free gas under the diaphragm on abdominal fluoroscopy. Patients with severe or debilitating peritonitis may show signs of shock. Patients with typhoid fever should have a slow pulse, decreased white blood cell count, and high body temperature, but after perforation, there is an increase in pulse rate, an increase in white blood cell count, a decrease in body temperature, and pus can be extracted by peritoneal puncture. However, sometimes patients do not have perforation but have symptoms of abdominal pain and distension, then a detailed examination should be made and careful consideration should not be made to perform a caesarean section hastily, so as not to aggravate the patient’s condition. Sometimes, there are a few slow although typhoid patients, but the symptoms are not obvious, only mild fever, headache, general discomfort, etc., do not cause the patient’s attention, still able to work, activities, belong to the proleptic type of typhoid fever. When perforation occurs in this kind of patients, it is mostly manifested as right lower abdominal pain with vomiting and signs of acute peritonitis in the abdomen, which is often misdiagnosed as perforation of acute appendicitis. In areas and seasons where typhoid fever is prevalent, one should be alert to the possibility of typhoid intestinal perforation.
Examination
1. Blood test
Leukocyte count increases on the basis of the original, more than 1/3 of the patients are more than 10×109/L, and individual can be more than 20×109/L (peritonitis stage).
2. Serum typhoid agglutination test (Fidelity test)
O antibody potency 1:80 or more, H antibody potency 1:160 or more, with diagnostic value.
3. Bacteriologic culture
Typhoid bacillus is found.
4. X-ray examination
In the vast majority of patients, free gas can be seen under the diaphragm.
Diagnosis
The diagnosis of perforated typhoid fever is considered at the time of the onset of acute abdominal symptoms. In addition, some patients have symptoms of typhoid fever but have not yet sought medical attention or a definitive diagnosis, so a detailed history should be taken. After perforation of typhoid fever, there is an increase in pulse rate, an increase in white blood cell count, a decrease in body temperature, and pus can be extracted by abdominal puncture. Therefore, it is not difficult to make the diagnosis when acute diffuse peritonitis is present in a patient who clearly has enteric typhoid fever.
Treatment
1. Surgical treatment
After the diagnosis of perforation of enteric typhoid fever with acute diffuse peritonitis is clear, preparation should be made immediately for surgical treatment, taking the right lower abdominal rectus abdominis incision or oblique incision, after excluding appendix and cecum lesions, the terminal ileum can be explored, generally within 100cm, the perforation can be found, and the perforation is mostly single, and after seeing the perforation, simple suture repair can be carried out. If the perforation is large and suture healing is expected to be a problem, the proximal bowel can be decompressed with a cannula stoma. In some cases, the thin wall of the lesion is close to the perforation, and the perforation can be closed by inversion suture. Patients with perforated enteric typhus are generally very weak, the operation should be simple and quick, and bowel resection should be carefully considered. At the end of the operation, the abdominal cavity should be well cleaned, and effective drainage such as double-lumen negative pressure drainage tube should be placed in order to reduce the occurrence of residual abscess and timely detection of intestinal fistula.
2.Drug treatment
Now the treatment of typhoid fever drugs such as ampicillin, ampicillin carboxylic acid, trimethoprim, norfloxacin, sulfamonomethyl isoxazole and so on, the effect is very good, postoperative strengthening of drug therapy can achieve the control of the development of the lesion, and less re-perforation occurs.
3. Postoperative treatment
In addition to the general postoperative treatment after surgery, the treatment of typhoid fever should be continued, and parenteral nutritional support can be given.