enteric fever, typhoid fever, surgical complications

1. TYPHOID Surgical Complications *DR. MANSOOR KHAN 28 th Oct, 2009 * Resident Surgical “C”, KTH, Peshawar

2. Salmonella a formidable killer! TYPHOID Surgical Complications TYPHOID Surgical Complications TYPHOID Surgical Complications TYPHOID Surgical Complications TYPHOID Surgical Complications TYPHOID Surgical Complications TYPHOID Surgical Complications TYPHOID Surgical Complications TYPHOID Surgical Complications TYPHOID Surgical Complications TYPHOID Surgical Complications TYPHOID Surgical Complications TYPHOID Surgical Complications

3. “ Potentially fatal, multi-systemic illness caused primarily by Salmonella typhi and paratyphi ”

4. Typhoid---ancient Greek Typhos, smoke or cloud that was believed to cause disease or madness

5. S. typhi, a major human pathogen for thousands of years , thriving in conditions of poor sanitation , crowding , and social chaos

6. 430–426 B.C. Killed 1/3 of the population of Athens , including their leader Pericles . The power shifted from Athens to Sparta . 2006 study detected DNA sequences similar salmonella

7. Antonius Musa A Roman physician who achieved fame by treating the emperor Augustus with cold baths when he contracted typhoid

8. Thomas Willis (1621-1675) The first description of epidemic Typhoid in 1659

9. Carl Joseph Eberth (1835-1926) Discoverer of the typhoid bacillus in 1880

10. Georges Fernand Isidor Widal (1862-1929) Demonstrated specific agglutinins in the blood of Typhoid patient in 1896---- “ The Widal Reaction”

11. History of typhoid epidemics

12. DISTRIBUTION

13. Infects roughly 21.6 million people each year * International Estimate Ramsden AE, Mota LJ, Münter S, Shorte SL, Holden DW. The SPI-2 type III secretion system restricts motility of Salmonella-containing vacuoles. Cell

14. Kills 200,000 people each year * International Estimate Ramsden AE, Mota LJ, Münter S, Shorte SL, Holden DW. The SPI-2 type III secretion system restricts motility of Salmonella-containing vacuoles. Cell

15. 62% of these occurring in Asia and 35% in Africa * International Estimate * Taylor TE, Strickland GT. Malaria. In: Strickland GT, ed. Hunter’s Tropical Medicine and Emerging Infectious Diseases. 8th ed. Philadelphia: WB Saunders, 2000:614-43.

16. Highest in Pakistan & India in Asian countries (451.7 per 100,000) * WHO Estimate * Bull World Health Organ vol.86 no.4 Genebra Apr. 2008

17. S P R E A D

18. TYPHOID BLACK HAND

19. Best prevention Scrub of them off your hands Best prevention Scrub them off your hands

21. Bacteria are better scientists than we are War of survival—they are working out very hard

22. RISK FACTORS

23. S. typhi are able to survive a stomach pH as low as 1.5 . Antacids , (H2 blockers), PPI’s, gastrectomy, facilitate S typhi infection TYPHOID FEVER RISK FACTORS

24. Contaminated food, House hold with Cases, Inadequate hand washing, , drinking unpurified water, and living without a toilet Environmental/behavioral risk factors TYPHOID FEVER RISK FACTORS

25. PRESENTATION Incubation period is 7-14 days

26. FIRST WEEK TEMPERATURE PATTERN

27. Diffuse abdominal pain , Inflamed Peyer patches narrow the lumen-- Constipation . Dry cough, dull frontal headache , delirium, increasingly Stupor & malaise FIRST WEEK OTHER SYMPTOMS

28. Rose spots , blanching, truncal, maculopapules usually 1-4 cm wide, < 5 in number; these generally resolve within 2-5 days ( bacterial emboli to the dermis ) FIRST WEEK OTHER SYMPTOMS

29. Distended abdomen, Soft splenomegaly , Relative bradycardia & dicrotic pulse (double beat, the second beat weaker than the first) SECOND WEEK

30. Patient may descend into the typhoid state- --apathy, confusion, and even psychosis THIRD WEEK TYPHOID STATE

31. Necrotic Peyer patches, bowel perforation, Peritonitis, intestinal hemorrhage may cause death THIRD WEEK Week of complications

32. Fever, mental state, and abdominal distension slowly improve over a few days, complications may still occur in surviving untreated individuals FOURTH WEEK WEEK OF CONVALESCENCE

33. COMPLICATIONS Immunity, antacids, vaccination, previous exposure, virulence, inoculum, choice of antibiotics

34. GENERAL COMPLICATIONS

35. Bilateral Salmonella typhi breast abscess unmarried 35-year-old female without any predisposing conditions Singh S, Pandya Y, Rathod J, Trivedi S. Bilateral breast abscess: A rare complication of enteric fever. Indian J Med Microbiol [serial online] 2009 [cited 2009 Oct 16];27:69-70. Available from: http://www.ijmm.org/text.asp?2009/27/1/69/45176

36. MEDICAL COMPLICATIONS

37. MAJOR SURGICAL COMPLICATIONS

38. MAJOR SURGICAL COMPLICATIONS

39. Morbidity 55.4% mortality 28.5 % INTESTINAL PERFORATIONS 5% of people with typhoid fever experience this complication DS00538 April 10, 2008© 1998-2009 Mayo Foundation for Medical Education and Research (MFMER). Typhoid enteric perforation, Dr Y. Akgun *, B. Bac, S. Boylu, N. Aban, I. Tacyildiz, British Journal of Surgery Volume 82 Issue 11, Pages 1512 - 1515 Published Online: 8 Dec 2005

40. Ileum especially distal ileum , jejunum usually does not perforate in typhoid, usually happens in the third week

41. MECHANISM OF INTESTINAL PERFORATION Intestinal peyer’s patches

42. 2 or 3 weeks hx of disease, with suddenly worsening of pain & general conditions , Tenderness starts in his right lower quadrant, spreads and eventually becomes generalized, Guarding , (seldom the board-like rigidity) Erect film, shows gas Under diaphragm (50% positive) lateral decubitus film, shows gas under his abdominal wall The bradycardia and leucopenia of typhoid may occasionally mask the tachycardia and leucocytosis of peritonitis PRESENTATIN PERFORATION

43. PATIENT PERFORATION

44. If peritonitis seems to be localized , signs confined to only part abdomen, general condition is good , patient not deteriorating , consider non-operative treatment . If signs of generalized peritonitis, do a laparotomy CONSERVATIVE SURGICAL VS

45. “ Suck and drip” Resuscitation, antibiotics, pass a NG-tube, Monitor abdominal tenderness, pulse, temperature, white blood count. If any of these rise, suspect that peritonitis is extending, so take an erect X-ray film of his abdomen CONSERVATIVE MANAGEMENT

46. MDR-area MDR+NAR-area MEDICATION TREATMENT WHO RECOMMENDATIONS

47. Do not forget to cover anaerobes and gram negative bacteria along with salmonella

48. Operate as early as possible , Do as much as necessory & as little as possible SURGICAL MANAGEMENT PREPARATION Adequately resuscitate, Maintain good urine output, pass nasogastric tube down, Start chemotherapy.

49. *Agbakwuru EA, Adesunkanmi AR, Fadiora SO, Olayinka OS, Aderonmu AO, Ogundoyin OO et al A review of typhoid perforation in a rural African hospital. West African Journal of Medicine 2003; 22(1):22-25. (13 kb) Abstract only Surgery Steps

50. Surgery Steps

51. Surgery Steps

52. Surgery Steps

53. CLOSE THE ABDOMEN Completely Without drains Drains are counter productive Surgery Steps

55. S P E C I M E N S John Hunter (1728-1793)

56. INTESTINAL HEMORRHAGE Occurs in 10-20 per cent of the cases

57. Intestinal bleeding is often marked by a sudden drop in blood pressure and shock, followed by the appearance of blood in stool Hemorrhage presentation

58. replace the blood loses. Bleeding usually stops spontaneously Only operate if bleeding is persistent, or alarmingly INTESTINAL HEMORRHAGE

59. Surgery Intestinal Hemorrhage

60. TYPHOID CHOLECYSTITIS

61. Occurs in 1-2% of cases *According to Indian study 8% More common in children Antibiotic resistance & virulence of bacteria *M.L. Kulkarni, SJ. Rego, Department of Pediatrics, J.J.M. Medical College, Davangere 577 004. Acute Acalculous Cholecystitis TYPHOID

62. *Thickened gall bladder wall, sonographic Murphy's sign, pericholicystic collection in the absence of gall stones *Subha Rao SD, LewinS, Shetty B, et al. Acute acalculous cholecystitis in typhoid fever. Indian Pediatr 1992, 29: 1431-1435. Acute Acalculous Cholecystitis TYPHOID

63. Unlike other AACs, antibiotic therapy is the recommended treatment for Typhoid AAC Acute Acalculous Cholecystitis TYPHOID

64. Chronic Cholecystitis (Carriers) TYPHOID Excretes bacteria in stools for more > 1 year1-4% of non-treated infected patients become chronic carriers Patients with cholelithiasis, biliary anomalies, females, Salmonella can be cultured from stools, duodenal aspirate, gall stones

65. Mary Mallon (September 23, 1869 – November 11, 1938) Forcibly quarantined twice, she infected 47 people , three of whom died . She died in quarantine.

66. Biliary anomalies, stones--requires cholecystectomy + antibiotics 4-6 weeks antibiotic treatment Chronic Cholecystitis TYPHOID

67. MAJOR SURGICAL COMPLICATIONS

68. MAJOR SURGICAL COMPLICATIONS

69. Typhoid Enteric Perforation: Prognostic Factors an Experience with 76 Patients J Ayub Med Coll AbottabadJan - Mar 2000;12(1):49-52.Department of Surgery, Khyber Teaching hospital, Peshawar

71. Arkadiy Stavrovskiy , Typhoid. 1932 Oil on canvas

72. OIL ON CANVAS

73. Ty21a —Oral live attenuated vaccine

74. Vi-CPS — parenteral vaccine

75. Good food handling & water sewage treatment can eliminate typhoid Prompt anntibiotic therapy can save many lives—take it a serious job Severe vomiting, diarrhoea & abdominal distension--- complicated, admit them & give IV antibiotics and support Prognosis of complications depends on the time-lapse b/w onset & treatment TYPHOID Surgical Complications TYPHOID Surgical Complications TYPHOID Surgical Complications TYPHOID Surgical Complications TYPHOID Surgical Complications TYPHOID Surgical Complications TYPHOID Surgical Complications TYPHOID Surgical Complications TYPHOID Surgical Complications TYPHOID Surgical Complications TYPHOID Surgical Complications TYPHOID Surgical Complications TYPHOID Surgical Complications take home message killer salmonella formidable

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