Typhoid Perforation of the
Appendix: a Rare Clinical Entity
Theophilus Bhushan,* Amer T. Irhuma,**
Mahmood Hussein***
Abstract: Bleeding and
perforation of the intestine are the most major complications of typhoid fever.
Perforation usually occurs in the 2nd or 3rd week of the
illness. Common sites of perforations are ileum, jejunum and caecum in order of
frequency but perforation can occur in any part of the gut at any time during
the illness.1
Key words:- Typhoid fever, perforated appendix, laparotomy.
Introduction:
Intestinal
perforation mainly occurs in ileum, jejunum, or caecum but can occur in any
part of the gut. We report two cases of typhoid perforation of the appendix:
one in a child and another in an adult. A 7-year old boy was presented with
febrile convulsions and peritonitis. His widal test was positive both
pre-operative as well as post-operative period.
Appendical perforation due to typhoid fever is a rare clinical
presentation; hence it is being reported.
Case report:
first Case.
A 7-year old
Libyan boy was initially admitted to the pediatric ward on 23/3/2002 with h/o high fever and
convulsions lasting for periods of 5 minutes and 30 minutes prior to admission.
Seven days of
fever preceding admission he was treated with anti pyretics at home. The boy had constipation for 4 days and lower
abdominal pain with dysuria for one day prior to admission. He was immediately
treated with IV diazepam, cold sponging and rectal paracetamol suppository. There
was no past medical history of any major illness or epilepsy; immunization was
complete.
O/E the child
was ill, febrile (38.5 c) and dehydrated but conscious and oriented.
Vital signs
were BP 90/60 P 120/mm RR 20/mm. Blood sample was obtained for
investigations. (see table 1).
On the 2nd
day of admission, the child was more alert, but still ill, febrile and mildly
dehydrated. His abdominal examination showed guarding, tenderness and rigidity
more in the lower abdomen.
The child had
vomited twice and complained of lower abdominal pain and dysuria .
Surgical
consultation was sought and the patient was transferred to the surgical ward.
A surgical team
reviewed the history and examination and confirmed the diagnosis of peritonitis
and further investigations were carried out as to the cause of peritonitis. He
was kept on N.P.O. I.V. fluids started with other supportive treatment.
The patient
started having a foul smell due to a large quantity of loose stool about 6
times in the surgical ward. The stool was sent for routine examination and
culture.
On PR
examination there was no boggy mass only mild rectal wall tenderness.
Chest X-ray and
abdominal X-ray was non-contributory; all blood examination was repeated. Widal
test was done. Ultra sonography was performed by a senior radiologist, which
was reported as highly suggestive of acute appendicts. The patient was well
dehydrated, fever was controlled, triple antibiotics regimen (ampicillin,
gentamycin & flagyl in appropriate dosage) was started. The patient was
taken up for surgery on 25th
March 2002 . Under G.A. with E.T.T. After routine aseptic cleaning
and drapping, right lower oblique incision was made. Findings were: there was
congestion with a few areas of hyperemiea over the ileum and caecum.
Appendix was
acutely inflamed, thick and edematous having tiny perforation at the tip,
surrounded by a small amount of peri appendical fluid. There was no free pus or
collection in the pelvis.
Classical
appendectomy was performed and warm saline lavage done. Abdomen was closed with
a tube drain. Post-operative period was uneventful except for a gradually
subsiding fever and loose stools. Sutures removed on the 7th day and
the patient was discharged on the 8th day. He was put on augmentin and multivitamin
syrup as pre-operative and post-operative widal test was positive.
*
Lecturer in Surgery, 2nd March
Hospital (University Teaching
Hospital) Sebha , Libya
**
Con. Surgeon & HOD Surgery, 2nd
March Hospital
(University Teaching Hospital) Sebha ,
Libya
***
Consultant radiologist, 2nd March
Hospital (University Teaching
Hospital) Sebha , Libya
Table 1: investigations of first case
|
1
|
Urine
examination
|
Pus cells
10-12. RBC 6-8, Bacteria ++
Epeth cells
++ sugar – Neg. proteins -+
|
|||
|
2
|
Stool
examination
|
Cyct, larva
ova –neg. puscell, RBC 0-1/HPF
|
|||
|
|
|
23rd
|
25th
|
30th
|
|
|
3
|
CBE
|
11.800
|
7.4x103
M/L
|
9.3x103
M/L
|
|
|
|
Hb
|
-
|
10.5 g%
|
12g%
|
|
|
|
PLT
|
-
|
144x103
|
618x103
|
|
|
|
Poly
|
-
|
73.4%
|
62%
|
|
|
4
|
Stool Cls
|
No growth
|
|||
|
5
|
Widal test
|
S. typhi H.
1:160
S.
paratyphi’B’ 1:80
|
0n 24th
& 30th
|
||
|
6
|
Chest X-ray
|
No gas under
diaphragm
|
|||
|
7
|
Abdomen X-ray
|
Few gaseous
distention of
|
|||
|
8
|
Sr. chemistry
|
BS 74
mg% BU 19mg%, Na 138, K 2.8
|
|||
|
9
|
Bl group
|
A +
|
|||
|
10
|
|
Appendix
distended Non-compressible with small periappendical collection. Highly
suggestive of Acute appendicitis
|
|||
Table
2: Investigation of second case
|
|
23/5
|
25/5
|
26/5
|
29/5
|
|
Hb
|
16.28%
|
168%
|
15.79%
|
15
|
|
TLC
|
14.200/-
|
4.400/-
|
7.400/-
|
9.900/-
|
|
BU
|
24
|
30
|
32
|
--
|
|
Creat
|
--
|
--
|
--
|
--
|
|
Na
|
133
|
134
|
138
|
--
|
|
K
|
3.7
|
3.5
|
3.8
|
--
|
|
Ca
|
0.99
|
0.98
|
1.06
|
--
|
|
Plt
|
121x103
|
--
|
--
|
104x103
|
|
BS
|
176
|
87
|
--
|
--
|
Widal 25.5.02 pre-op.
STO - +
STH - +
SPTH.A +
SPTH. B +
Widal 29.5.02
STO 1:320
STH 1:320
CXR no gas
under diaphragm
Abdominal
x-ray – few gaseous distended large
bowel no air fluid level
USG – 1st
appendicular mass 6.5 x 5.5 well defined hydrogenous no free fluid in the
abdomen or pelvis.
USG – 2nd
appendix thick walled 5.2 x3.4 with calcification. No localized collection, no
free fluid. Bowel engorged thick walled no perforation.
2nd
Case:
A.S. 27 years
Libyan male from Marzuk was admitted on 23.5.02 with acute pain abdomen of 4
days duration associated with vomiting and fever for one day.
He was admitted
in Marzuk hospital for one day and transferred here for further management.
On examination
the patient is tall, well built, febrile, ill looking and dehydrated.
His vital signs
were Bp 130/80 p. 120/min RR 18/min and T-39˚c. Respiratory and cardiovascular
systems were unremarkable. Abdominal examination revealed, mild distension,
tenderness over RIF with guarding and
rigidity.
There was
palpable mass in RIF about 4.5 cmx 5 cm. There
were no signs of generalized peritonitis.
Clinical
diagnosis of Appendicular mass was made and conservative line of treatment
adopted. He was kept n.p.o, fluids started, antibiotics Rocephin 1gx2, flagyl
500mgx3 iv given with other supportive measures.
Blood was
obtained for detailed investigations including widal which was positive (see
the table). The patient was on conservative line of management but did not
improve.
His pyrexia,
tachycardia and abdominal tenderness and toxic state made us to decide for
laparotomy. Laparotomy was performed on 25.5.02 under G.A. with E.T.T. and the
abdomen was opened through ® lower paramedian incision.
The findings
were inflamed, supprative, gangrenous appendix with perforation at the tip
surrounded by localized collection of pus.
The caecum,
ileum were thick, edematous, adherent with fibrinous plaques.
Careful lysis
of adhesions, through warm saline lavage performed appendectomy done by gentle
handling of the bowel.
Tube drain put
and the abdomen was closed in layers.
Postoperative
period was less stormy as fever, tachycardia abdominal pain gradually settling
down.
Catheter, NGT
were removed subsequently in 3-4 days time after resumption of good bowel
movements.
Post-operative
widal test was positive. STO 1:320 and STH 1:320. He was put on CIPROX 500mgx2
and B complex tablets with advise on regular follow up 2 wkly.
He was
discharged on 29.5.02 in good general condition.
Discussion:
Typhoid fever
is endemic in most tropical countries and is caused by ingestion of salmonella
organisms. Most severe symptoms are produced by S. Typhi about 200 cases occur
per year England
Organisms may
survive in gall bladder and urinary tract having invaded through small
intestinal mucosa after multiplication in bile rich area in the 2nd
part of duodenum.3
Organisms may
be take-up by any part of the body but usually enter payers patch mostly in
ileum and jejunum. Here ulceration develops and possible hemorrhage and
perforation takes place, which occurs, in the 3rd week of the
disease.4
Although
typhoid fever affects many organ system but the most serious complications
occur in .GI. tract. G.I. hemorrhage and intestinal perforation are serious
complications of typhoid fever and responsible for most of the fatalities.5
G.I. Hemorrhage is reported form 0.8% - 5%
Perforation is
reported around 5% (0-39%).6
|
Incubation
|
Clinical
|
bacteremia
|
complication
|
Mortality
|
|
S.
Typhi
10
days
|
Typhoid
fever
|
>90%
|
Intestinal
perforation & hemorrhage
|
2-32%
|
|
S.
Typhi
A-B-C
10-14
days
|
Paratyphoid
fever
|
>90%
|
Intestinal
complications less common
|
<2%
………
(7)
|
Perforation of
the gut commonly occurs in the 2nd or 3rd week of typhoid
fever and can occur at any time of the illness. In the hospital it may be
observed in a child is aten associated with sudden deterioration Hypotension,
tachycardia and abdominal rigidity as it was seen in our patient. He was
admitted with febrile convulsions. Proceeding 7 days of fever and the next day
he was found to have peritonitis.
Some times the
perforation is less dramatic resulting in paralytic ileus.8 When
perforation occurs, a fit patient will show all the signs of peritonitis as in
our patient, but the seriously ill patient may show very little signs of
abdominal tenderness guarding and rigidity.
Some times
confusion occurs due to the rupture of inf. Epigastric artery in typhoid fever
and there is similar tenderness in R.I.F.9
Management of perforation has been controversial in the
absence of controlled prospective study most authors currently advocate
operative rather than non-operative treatment. Operative treatment is preferred
because typhoid fever produces fulminate peritionits unlike other perforations.
Patients are usually critically ill, septicemic, often dehydrated and have
electrolyte imbalances.10
At laparaotomy,
usually a single perforation is found in the antimesentric border of ileum in
80%, and two perforations in 15%, about 50% of the perforations are located
within 40 cm of ileum. 2% of perforations are seen in caecum.11
At laparotomy,
bowel is very friable and should be handled very gently. Whether perforation is
over sewn or resection done depends on the findings at laparotomy.12,13
Mortality:
Intestinal
perforation is the leading cause of death in collective series in the developing
countries mortality is around 43%. Time interval between the perforation and
surgery is critical for better prognosis. And best results are obtained if
operated with in 24 hours.14
Conclusion:
Typhoid
perforation of the appendix is a rare complication. In our case both pre-op. as
well as post op. Widal test was positive in the adult patient, Paratyphoid B,
S. typhi H was positive and S.T.O was significantly absent. We are of the
opinion it could be paratyphoid perforation which is about 2% in Occurrences.
Child is doing well in subsequent follow-ups. Adult male patients went to his
home-town and not returned.
We feel in all
the unusual type of acute appendicitis with high fever of more than 3-4 days
widal test should be done for proper management.
Acknowledgement:
We appreciate the active
participation of Dr. Einas, Dr. Awad, SHO surgery and Dr. Ferdous intern
pediatrics in patient care.
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1985; 7:257.
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13. Butlar T. et.al. Rev Infect Dis,
1985, 7:244.
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Varrassi G, Donatelli F and Marinangeli F. Organization of an acute pain
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methods. Pain 1986; 27: 117–26.
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