Introduction

Typhoid fever is a preventable as well as a curable disease. Worldwide distributed and linked with a poor sanitation practices it is a considered an infectious disease cause by Salmonella cholera suis serotype typhi. Humans are the only host and reservoir, most occurring in Asia or Africa with a peak in dry hot months by food contaminated by carrier (epidemic area) or by contaminated water (endemic area). After ingestion occur lymph node invasion, initially Peyer’s Patches in terminal ileum later spreads to mesenteric lymph nodes, it enters blood stream via thoracic duct and dissemination occur with reticuloendothelial system infected and persistent bacteriemia, mucosa penetration most common in terminal ileum (perforation) and or hemorrhage are the most common intestinal complication occurs in third week^1,2,3,4,5,6

Perforated typhoid (TP) with established peritonitis is not a rare complication in our region, and we found it as a common complication among admitted patients at Umtata General Hospital (Eastern Cape province) from South Africa, and most patients sustained it qualified to be admitted in Intensive Care Unit.

Umtata General Hospital serve as a referral hospital for 25 rural hospitals, nearest 30 Km away (San Barnabas) and furthest 225 Km away (Rietvle) with a total of 1149 beds serve a population about 6.4 millions. I.C.U. is the main unit for critical ill patients with 9 beds available for children and adult.

Patients and Methods.

This is a retrospective as well as a prospective study of all patients admitted in I.C.U. with the diagnosis of typhoid perforation between year 1999 to 2002 emphasis was put on sex, age, indication for I.C.U. admission, duration of stay and outcome.

A total of 113 patients were admitted from 141 operations done with the diagnosis of established peritonitis due to T.P., in all cases the diagnosis was confirmed through operative findings on the operating theatre.

Results

Seventy eight male patients were admitted (69 %) and 36 females (31 %), the age average was between 6 years the youngest, and 60 years old the oldest one; the average for males was 18,2 years and 19,6 years for females. 65 patients were admitted before operation and 48 patients after operation with a stay average of 6 days the shortest, and 18 days the longest one.

It was found in 8.4% in 1999 , 5.9 % in 2000, 5 % in 2001 , and 6.1 % in 2002 (see table I)

Table I: Show the total of non-trauma emergency operations done yearly
and the overall- established peritonitis due to T.P

In 1999 admissions represented 56% during 2000 were admitted 81% in 2001 were admitted 92.5% and year 2002 were admitted 100% (Table II). Several complications pre and post operation was an important factor to take in consideration as well as deterioration of patients’ condition.

Table II: It is showed increased number of admission due to T.P. with established peritonitis
took place in ICU yearly.

Standard mid line laparotomy was the procedure of choice in all patients, identification of lesion and excision of edges for biopsy, suture of single, double or triple perforations, occasional resection and primary anastomosis in case of multiples perforations and copious peritoneal lavage. Closure of the wound, no drain no ileostomy was done. Relap was needed to be implemented in 7% of overall patients .

Perforation of terminal ileum was found in 100% of patients with pus in the abdominal cavity. Single perforation was found in 83 patients (73.4%) two perforations was found in 15 patients (13.2%) and more than two perforations was found in 15 patients (13.2%).

Either pre or post operative complications was found in 100% of patients (See Table III)

Established peritonitis	100%
Hematological Disorders	77%
Anemia	89%
Thrombocytopenia	93%
Septic Shock	77%
Electrolytes Imbalance	71%
Hypoalbuminemia	69%
Intestinal obstruction	47%
Pneumonia	23%
Renal Failure	22%
Respiratory Distress	18%
Multiple Organ Failure	8.8%

Table III

Death due to TP is high ranged from 20 to 26% with a mean of 23% (Table IV).

Table IV

The most common cause of death was septic shock (17 patients) which represented 77.2% From this group 9 patients (52%) sustained multiple organ failure, respiratory distress syndrome, and acute renal failure was also another cause of death.

The empirical association of claforan-gentamycin and flagyl was established in 50 patients (44%) while the association of chloramphenicol-gentymicin and flagyl was established in 63 patients (56%) and no significant importance in patients overcome Nonetheless one the diagnosis is made, it is recommended the use of chloramphenicol because of the disadvantages of non oral claforan available

Conclusions

Established severe peritonitis was the main indication for ICU admission in those with the diagnosis of TP.The delay in reaching the hospital as well as the delay in started resuscitation management and perform the definitive operation are negative factors in patients outcome. Mortality is increased in associated septic shock (77.2%) with or without multiple organ failure.

There were no significative differences between the empirical association of chloramphenicol- flagil-gentamycinor or claforan–flagyl-gentamycin.

References

1. Ahmet Y et al. Clinical and laboratory presentation of Typhoid Fever in hospitalized children : A review of 314 cases in the Southeastern Region of Turkey. Int Ped. 2002;16:25-35.
2. Bogale W. Thyphoid fever in Ethiopian children’s hospital 1984-1995. Eth J Health Dev. 2000;14(3):311-315.
3. Coll J. Thyphoid perforation. Col Surg Edinb 1972;153-163.
4. Surgical complications. Surgery, Chapter 23. available on line from: http://www.worldorth.com
5. Kazamizar T. Treatment of typhoid fever. Available on line from: http://www.sums.ac.ir/semj/vol1/jan2001/kazamifar1.htm
6. Williams K. Typhoid ileal perforation. Available on line from: http://www.rcsed.ac.ur/old.htm
7. Ogunsawo G. Pronostic factors of typhoid perforation in Lagos. Available on line from: http://www.inasp.org.uk/ajol/journals/nqjhm/vol9n1labs.html

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Comentario del Dr. Moisés Morejón García. Hospital Universitario Manuel Fajardo. La Habana. Cuba

Muy interesante el trabajo de los Dres. Fernadez- Mena C y Col. con una casuística no muy común en muchos países, por tanto considero que tiene una vasta experiencia en el manejo de estos casos.

Me llamó la atención que los resultados obtenidos con las dos antibioticoterapia fueron similiares, se ha hablado mucho de los niveles preocupantes de resistencia que ha adquirido la S. typhi frente al Cloranfenicol así como frente al Ampicillin y Sulfaprin, llegando en algunos lugares a recomendarse las Cefalosporinas de 3ª generación (Ceftriaxona y Cefotaxime) como antimicrobianos de primera línea o las Quinolonas (Ciprofloxacino o Ofloxacino), recordando incluso que se han descrito también cepas resistentes a quinolonas. Al parecer los autores no han encontrado relación entre este evento y los casos que no evolucionaron satisfactoriamente.

Los elementos relacionados con la evolución insatisfactoria (llegada tardía al hospital y demora del acto quirúrgico) se ponen una vez más en evidencia en este tipo de patología.

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Comentario del Prof. José Mª Eiros Bouza. Hospital Clínico Universitario. Valladolid. España.

La importancia que reviste la Fiebre tifoidea en Europa o Norteamérica no es comparable a la que presenta en otras zonas del Globo. Prueba de ello es la presente serie de la que cabe retener al menos tres aportaciones fundamentales.

En primer término la existencia de dos especies de Salmonella implicadas en su etiología. En segundo lugar el hecho de que los pacientes revisados pertenecen a un segmento etario joven. En tercera instancia la gravedad de sus complicaciones, que son el objetivo primordial del estudio, entre las que destaca la peritonitis que se asocia a shock séptico y requiere valoración y asistencia en unidades de cuidados intensivos.

Como muy bien comenta el Dr Morejón los resultados referentes a la antibioterapia son muy relevantes en cuanto a la eficiencia de las pautas empleadas. El artículo nos recuerda la necesidad de tener presente a la Fiebre Tifoidea en el diagnóstico diferencial del abdomen agudo en pacientes asistidos o que hayan viajado recientemente a estas latitudes.

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Comentario del Dr. Javier S. Mazana.Universidad de la Laguna. S/C de Tenerife. España

El tema del trabajo es muy atractivo y oportuno sobre todo para los cirujanos de los paises industrializados, en un campo como es la cirugía de urgencia que en nuestro caso adquiere más relevancia en el contexto epidemiológico y de salud pública en el que nos encontramos. Los autores de esta publicación adscritos a la universidad de Transkei (UNITRA) en Umtata, Sudáfrica (cuya apertura oficial fue el 6 de mayo de 1977), y que está sometida a la Revista Electrónica de Biomedicina, nos presentan la casuística de los enfermos con perforación tifoidea de su hospital en el periodo de 1999 al 2002. La perforación intestinal produce un cuadro abdominal agudo y representa la complicación más grave de la fiebre tifoidea. En esta serie, la localización en íleo terminal afecta al 100% de los pacientes. El shock séptico es un signo de mal pronóstico y la principal causa de muerte. Se asocia a peritonitis. Debe sospecharse cuando aparezca bradicardia, leucopenia y perforación en un enfermo febril con hipersensibilidad en fosa iliaca derecha.

Salmonella Cholera suis es un patógeno que puede producir bacteriemia con o sin metástasis asociadas. La quimioterapia antimicrobiana ha resultado eficaz tal como acertadamente se enfatiza en el artículo. Las 4-fluoroquinolonas constituyen una terapia adecuada en todas las formas de salmonelosis, incluyendo enterocolitis, por varias razones: pueden administrarse por vía oral, son eficaces frente a cepas multirresistentes y poseen un elevado nivel de penetración tisular. En cuanto a sus inconvenientes destacan el elevado coste económico y la contraindicación de su empleo en pacientes menores de 18 años. Algunos estudios han demostrado que las quinolonas prolongan la excreción de salmonelas en heces, aumentando de este modo la duración del estado de portador fecal, pudiendo asociarse a recidivas y a la aparición de resistencias, por otra parte raras.