Journal of Clinical and Diagnostic Research.

2013 Sept, Vol-7(9): 1946-1948 1946 1946

DOI: 10.7860/JCDR/2013/6632.3366
Original Article

Mortality in Typhoid Intestinal
PerforationA Declining Trend
Key words: Typhoid fever, Intestinal perforation, Mortality
ABSTRACT
Background: Typhoid fever is an important public health
problem in developing countries. Intestinal perforation is one
of the leading fatal complications of typhoid fever. Typhoid
perforation occurs more commonly in terminal ileum. Morbidity
and Mortality associated with typhoid perforation are high
(9-22%). However this study aims to know whether there are
any changes of the same.
Aim: To analyse the clinical presentation, management,
complications, morbidity and mortality associated with typhoid
intestinal perforation and assess changing trends in mortality in
typhoid intestinal perforation.
Material & Methods: This is a retrospective observational study.
Cases regarding the study have been analyzed by reviewing the
patient records. It includes 40 patients who were diagnosed
with typhoid intestinal perforation, admitted and treated in the
Department of General Surgery from February 2011 to January
2012.
Results: A total of 40 patients were considered for the study
and their mean age was 35.75 years. 80% of patients were
male. Pain abdomen was their main symptom which lasted for
an average of 2.95 days. Leukocytosis (11,000 cells/cumm)
was present in 57.5% patients. Single perforation was present
in 31(77.5%) patients and primary closure was done in 30 of
them. Culture sensitivity showed E coli as the main organism.
Complications were seen in 42.5% of patients in postoperative
period.
Conclusion: Early recognition, timely surgical intervention with
appropriate surgery and antibiotics, and effective peri-operative
care reduces the mortality in typhoid intestinal perforation.

ANUPAMA PUJAR K.
1
, ASHOK A.C.
2
, RUDRESH H.K.
3
, SRIKANTAIAH H.C.
4
, GIRISH K.S
5
, SUHAS K.R.
6
INTRODUCTION
Typhoid fever is a febrile illness caused by Salmonella typhi, a
gram negative bacillus. This infection remains an important public
health problem in developing countries [1]. The most dreaded
complications are haemorrhage and intestinal perforation. Typhoid
fever is a predominant cause of nontraumatic intestinal perforation
in developing countries [2]. The high incidence of perforation in most
of the developing countries has been attributed to late diagnosis, the
emergence of multidrug resistant and virulent strains of Salmonella
Typhi [1]. Frequency of perforation varies between 0.8% and 18%
[3]. Perforation occurs in the terminal ileum secondary to necrosis
of Peyers patches about 23 weeks after the onset of disease.
Perforation of terminal ileum is a cause of obscure peritonitis
particularly in patients with severe toxic state, delaying diagnosis and
surgical intervention [2]. Despite decades of improvements made
in patient care, the morbidity and mortality of patients with typhoid
perforation remains high, and this is related to multiple factors
[4]. However, early surgical intervention is regarded as denitive
treatment along with preoperative resuscitation and postoperative
intensive care [3].
AIMS AND OBJECTIVES
To analyse the clinical presentation, operative ndings, surgical
procedures, postoperative complications, morbidity and mortality
associated with intestinal perforation due to typhoid fever in a
tertiary care center and to study changing trends in mortality in
typhoid intestinal perforation.
MATERIAL AND METHODS
This study included 40 patients, diagnosed with typhoid intestinal
perforation admitted and treated in the Department of General
Surgery from February 2011 to January 2012. Retrospectively
the cases were analyzed by reviewing the patient records after
approval from the ethical committee. The cases were evaluated
with regard to age, gender, clinical features, investigations, intra
operative ndings, type of surgery, morbidity and mortality. All
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patients initially presented to the emergency department because
of acute abdomen. They were subjected to erect Xray abdomen,
chest Xray PA view, complete blood count, urine analysis, renal
function test, serum electrolytes, ultrasound abdomen. All patients
underwent surgery after preoperative resuscitation within 6 hours of
admission. All were given 3
rd
generation Cephalosporins (preferably
Ceftriaxone) with Metronidazole, with or without Amikacin.
STATISTICAL ANALYSIS
Descriptive statistics comprising of percentage (proportion) and
mean ( standard deviation) were used to describe the patient
characteristics and morbidity/mortality prole.
RESULTS
Out of the 40 patients, 32 (80%) were male. The youngest was 14
years old and oldest was 65 years with mean age of 35.75 years.
Twenty three (57.5%) patients presented with intestinal perforation
within seven days of onset of fever [Table/Fig-1]. The most
common presentation was pain abdomen seen in 38 patients
with mean duration of 2.95 days. Twenty one patients had history
of pain abdomen less than 2 days. Bowel disturbances were
present in seventeen (42.5%) patients, Out of whom 8 patients
had constipation, 7 patients had loose stools and 2 patients had
vomiting. Comorbidities were also present in two patients. One
patient had hypertension and another patient had diabetes. Eleven
patients were diagnosed to have typhoid fever and received
antibiotics prior to hospitalisation for perforation.
On examination 30 (75%) patients had diffuse peritonitis, eight
(20%) patients had localised peritonitis whereas 2 (5%) patients
had no peritonitis. Twenty three (57.5%) patients had leukocytosis
(>11000cells/cumm), and only one patient had leukocyte count
less than 4000cells/cumm. Neutrophils were more than 80% in
24 (60%) patients. A simple erect chest Xray demonstrated gas
under diaphragm in 34 (85%) patients. Remaining patients were
subjected to ultrasound/CT scan for diagnosis.
www.jcdr.net Anupama Pujar K. et al., Changing Trends in Typhoid Intestinal Perforation
Journal of Clinical and Diagnostic Research. 2013 Sept, Vol-7(9): 1946-1948 1947 1947

Key words: Typhoid fever, Intestinal perforation, Mortality
be because of the compromised nutritional status in patients who
had been ill for more than two weeks and perforate.
Typhoid intestinal perforation is seen during the second and third
decades of life [3,7]. In this series mean age was 35.75 years.In
a study by Atamanalp et al., [8], mean age was 36.3 years and in
a study by Sumer et al., [3] mean age was 37 years. It has been
found that being male is an independent risk factor for intestinal
perforation [9]. Khan et al., reported typhoid perforation more
common in males than females [10].
The most common symptoms are pain abdomen and fever [11].
In these series 38 patients presented with pain abdomen. Other
features are abdominal distension, constipation, vomiting and
loose stools. Guarding has been reported as the most common
physical nding [3].
In this study 85% patients had pneumoperitoneum demonstrated
on chest Xray and erect Xray abdomen. This is consistent with
study by Chalya et al., [1]. Leukopenia is the feature of typhoid
fever. In our series 57.5% had leucocytosis. 2.5% had leukopenia,
rest had normal total leukocyte count. A study by Santillana et al.,
leucocytosis was recorded in 59.5% of patients [12]. Leucocytosis in
typhoid fever suggests increased severity of typhoid perforation [9].
Widal test has been used in developing countries for diagnosing
typhoid fever but it has low sensitivity, specicity and positive
predictive value which changes with the geographical areas [13].
Typhidot is an immunochromatographic test which is easy and
rapid to perform and turn around time is one hour [14]. The gold
standard blood culture takes 2 to 4 days. In this study Widal was
positive in 32 patients (80%). In a study by Rahman et al., Widal
was positive in 75.90% of cases [15]. Typhidot was done in 15
patients and in seven patients it was positive. Five patients who
were widal negative showed typhidot positive.
Typhoid perforation mainly affects the terminal 40 cm of the ileum
in 72%78% of cases; the jejunum, caecum, colon and gallbladder
to lesser degree [16]. Rare case of appendicular perforation due
to typhoid has been reported in literature [17]. In this study 38
All the patients underwent midline laparotomy. Single perforation
of ileum was noted in 31(77.5%) patients, 5(12.5%) patients had
2 perforations and more than 2 perforations were present in
4(10%). Size of perforation varied from 0.5cm to 2cm. Location of
perforation was within 20cm from ileocaecal junction in 29(72.5%)
patients, 2040cm from ileocaecal junction in 9(22.5%) patients
and 2(5%) patients had perforation beyond 40cm from ileocaecal
junction. Peritoneal collection was purulent in 20(50%) patients,
feculent in 13(32.5%) patients and bile stained in 5(12.5%) patients.
Length of inamed bowel was less than 20cm from ileocaecal
junction in 31(77.5%) patients, 2040cm in 6(15%) patients and
3(7.5%) patients had bowel inammation more than 40cm from
ileocaecal junction.
The choice of surgical procedure was depended on patients general
condition, peritoneal contamination, inamed bowel, location and
number of perforation. Primary closure of perforation was done in
30(75%) patients out of 31 patients with single perforation. One
patient with single perforation had extensive bowel inammation
and feculent collection underwent resection anastomosis and
ileostomy. Eight patients who had 2 and more perforations
underwent resection and anastomosis with loop ileostomy. One
patient who had multiple perforations at ileocaecal junction
underwent right hemi colectomy and ileocolic anastomosis.
Postoperative recovery was uneventful in 23(57.5%) patients.
Seventeen (42.5%) patients had complications as shown in [Table/
Fig-2]. One patient underwent ultrasound guided aspiration for
intraabdominal collection. One patient developed enterocutaneous
stula which was managed conservatively. Three patients required
mechanical ventilation in postoperative period. Culture revealed
E coli as the main organism in 13 (32.5%) patients [Table/Fig-3],
Widal test was positive in 32 (80%) patients. Typhidot was done in
11 patients. It was positive in 7 patients.
Thirteen (32.5%) patients were discharged within 10 days. Twenty
ve (62.5%) patients were discharged between 10 to 30 days and
only 2 (5%) patients stayed in the hospital for more than a month.
[Table/Fig-1]: Distribution of duration of fever
of patients studied. (Mean SD: 8.467.76)
Duration of fever (days) Number of
patients
%
Nil 4 10.0
<7 23 57.5
7-14 3 7.5
14-21 7 17.5
>21 3 7.5
Total 40 100.0
Sl No. Study [References] Year No of Patients Studied Number of Mortality (%)
1 Kouame et al., [29] 1995-1998 64 22 (34%)
2 Agbakwuru et al., [27] 1988-2001 105 17 (16.2%)
3 Ansari et al., [25] 2003-2008 44 6 (13.36)%
4 Saxe et al., [29] 2003 112 18 (16%)
5 Sumer et al., [3] 1994-2010 22 1 (4.5%)
6 Our study 2011-2012 40 nil
[Table/Fig-4]: Comparison of mortality in different studies
[Table/Fig-2]: Distribution of post-operative
complications in patients studied
Complications Number of
patients (n=40)
%
Nil 23 57.5
Present 17 42.5
Surgical site infections 9 22.5
Chest complication 6 15.0
Enterocutaneous stula 1 2.5
Intra-abdominal abscess 1 2.5
[Table/Fig-3]: Distribution of organisms
isolated on culture of peritoneal collection
C/S Number of patients %
1. E coli 13 32.5
2. Enterococcus 5 12.5
3. ESBL (E-coli) 1 2.5
4. Klebsiella 4 10.0
5. None 17 42.5
Total 40 100.0
[Table/Fig-5]: Decline in mortality in typhoid perforation
DISCUSSION
Typhoid perforation usually occurs in 2
nd
to 3
rd
week of fever [1,3].
However in developing countries cases are reported early within
the rst week of illness [5]. In this study duration of fever was less
than 7 days in 57.5% of cases. The reason observed behind this
though unproven could be because of low immunity, change in
the virulence of the bacteria, hypersensitivity of Peyers patches to
bacteria [1]. The patients who perforated during the rst two weeks
of the illness appear to have a better prognosis [6]. This may also
patients had perforation in terminal 40 cm of ileum. Only two
patients had perforation proximally, at mid ileal level. Pathological
changes are not just restricted to perforation sites. The diseased
gut is characterised by diffuse nonspecic enterocolitis with
hypertrophy, necrosis and ulceration of intestinal and mesenteric
lymphatic tissue. This is the reason for the gut in patients suffering
from typhoid fever, mainly terminal 60 cm to be oedematous and
friable [2]. In this study the diseased bowel was less than 20 cm in 31
(77.5%) patients. This may be because our patients had perforation
Anupama Pujar K. et al., Changing Trends in Typhoid Intestinal Perforation www.jcdr.net
Journal of Clinical and Diagnostic Research. 2013 Sept, Vol-7(9): 1946-1948 1948 1948
in early course of disease. Once perforation occurs peritoneal
contamination depends on duration of perforation and number of
perforations. In this study majority (77.5%) had single perforation. It
has been reported that multiple perforations have signicantly high
mortality compared to those with single perforation [1].
Early surgery is the optimal treatment in typhoid perforations
despite appropriate antibiotics. It ceases the source of further
faecal contamination of peritoneal cavity [18]. In this study surgical
intervention was done within 6 hours of admission. Several surgical
procedures have been described in the form of simple closure,
wedge excision with simple closure of perforation, bowel resection
and anastomosis with or without ileostomy. Laparoscopic perforation
closure has been reported by Ramachandran et al., [19] and Sinha et
al., [20]. In this study primary closure was done in 75% patients. 25%
had an extensive procedure. Beniwal et al., [21] suggested primary
closure is the choice of treatment. Shah et al., founded resection
anastomosis and copious peritoneal lavage is the best surgical option
[22]. Malik et al., showed primary ileostomy to be the successful
procedure [18]. Husain et al., suggested closure of ileal perforation
with omental patch technique prevents the leak [23].
The main organism grown in peritoneal uid culture was E coli 13
(32.5%) patients. This is consistent with the study by Sitaram et al.,
[24]. Most common complication in this study was surgical site infection
which is similar to a study by Ansari et al., [25]. Enterocutaneous stula
was found in 1 (2.5%) patient similar to study by Sumer et al., [3]. This
was managed conservatively. Fistula closed spontaneously. In a study
by Ansari et al., stula was found in 13.4% patients [25] Major cause of
postoperative morbidity in perforation peritonitis according to Jhobta
et al., is respiratory complication [26]. In this study 6 patients (15%)
developed respiratory complication and 3 patients needed mechanical
ventilation in the postoperative period.
In developing countries mortality rates from typhoid perforation have
been reported to range from 922%[1].There was no mortality in our
series as compared to other studies [Table/Fig-4 and 5]. Agbakwuru
et al., who reported mortality rate of 16.2% [27] where in the patients
were operated 24 to 48 hours after diagnosis. Ansari et al., reported
mortality of 13.36% [25] where the patient presented with mean
duration of pain abdomen of 5.6 days. In their study 4 out of 6 deaths
were due to development of faecal stula. In our series, most of our
patients (57.5%) presented within the rst week of fever and the mean
duration of pain abdomen was 2.95 days. Koume et al., reported
high mortality due to complications related to ileostomy [28]. Saxe
et al., attributes mortality in his study to persistent sepsis which he
says could have been prevented by using broad spectrum antibiotics
[29]. There was no mortality in our study probably due to early and
appropriate surgical intervention, effective pre and peri-operative
resuscitation, post-operative intensive care procedures, good
ileostomy care and delivery of broad spectrum antibiotics. Sumer et
al., reported low mortality attributed to similar reasons [3].
CONCLUSION
Typhoid intestinal perforation is a major surgical health problem
in tropical countries particularly in those where, standard of living
is low which leads to unhygienic environment. Early recognition,
timely surgical intervention, appropriate antibiotics and surgical
technique and perioperative care play key role in reducing mortality
in typhoid intestinal perforation. However, this is a retrospective
observational study. This has all the limitations of retrospective
study, to come to any opinion. This warrants a prospective study
to come to a denitive conclusion.
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PARTICULARS OF CONTRIBUTORS:
1. Assistant Professor, M.S. Ramaiah Medical College, Bangalore, India.
2. Professor, M.S. Ramaiah Medical College, Bangalore, India.
3. Professor, M.S. Ramaiah Medical College, Bangalore, India.
4. Associate Professor, Department of Surgery, M.S. Ramaiah Medical College, Bangalore, India.
5. Assistant Professor, M.S. Ramaiah Medical College, Bangalore, India.
6. Postgraduate Student, M.S. Ramaiah Medical College, Bangalore, India.
NAME, ADDRESS, E-MAIL ID OF THE CORRESPONDING AUTHOR:
Dr. Anupama Pujar K.,
No 1165, 5
th
main, 4
th
block, Hbr Layout, Bangalore560043, India.
Phone: 9740190687, E-mail: anupamapujar@rediffmail.com
FINANCIAL OR OTHER COMPETING INTERESTS: None.
Date of Submission: Jun 04, 2013
Date of Peer Review: Jun 19, 2013
Date of Acceptance: Jul 28, 2013
Date of Publishing: Sept 10, 2013