Typhoid enteric perforations

Forty-five cases of typhoid enteric perforation are presented. The disease was most common in young males. Half of the perforations occurred during the second week of fever. Diagnosis was mainly clinical, supplemented by radiological evidence of pneumoperitoneum and confirmed at laparotomy by the presence of perforations in the terminal ileum. Laboratory investigations including Widal test and blood culture were of little value. All the 45 were managed operatively by simple closure of the perforation(s) and drainage of the peritoneal cavity. Burst abdomen occurred in 9 per cent and fecal fistula in 20 per cent. Overall mortality was 11 per cent—much lower than that reported in the literature in case of management of typhoid enteric perforations.     

Typhoid enteric perforations

Forty-five cases of typhoid enteric perforation are presented. The disease was most common in young males. Half of the perforations occurred during the second week of fever. Diagnosis was mainly clinical, supplemented by radiological evidence of pneumoperitoneum and confirmed at laparotomy by the presence of perforations in the terminal ileum. Laboratory investigations including Widal perforations in the terminal ileum. Laboratory investigations including Widal test and blood culture were of little value. All the 45 were managed operatively by simple closure of the perforation(s) and drainage of the peritoneal cavity. Burst abdomen occurred in 9 per cent and fecal fistula in 20 per cent. Overall mortality was 11 per cent--much lower than that reported in the literature in case of management of typhoid enteric perforations.     

A contemporary evaluation of enteric perforations in typhoid fever: analysis of 257 cases

Of the 257 typhoid enteric perforations analysed at the Departments of General and Paediatric Surgery, Ankara University Hospital, through the years 1979-1986, 74.9% were males, while the patients mean age was 35.8 years. The early signs and symptoms averaged 5.9 days. The corresponding percentages for the occurrence of abdominal pain, fever, nausea and vomiting and central nervous system disorders which constituted the clinical findings were 97.27, 51, 61.2 and 18 respectively. While the mean value for the white blood count ranged around 6600, only 61.9% of the cases had diagnostic findings in their erect abdominal roentgenograms. The standard method for the treatment of typhoid enteric perforations is still presently primary suturing of the perforated viscus and peritoneal drainage. Despite the use and misuse of a large variety of antibiotics, typhoid perforations still have a high morbidity of 74.1% and a mortality of 31.4%. Generalized peritonitis (78.4%), is considered to be to the most important cause in both situations.     

Colonic enteric nervous system analysis during parenteral nutrition

Introduction

Parenteral nutrition (PN) is a necessary therapy used to feed patients with gastrointestinal dysfunction. Unfortunately, PN results in intestinal atrophy and changes to host immune function. PN may also induce additional effects on gut motility that we hypothesized would result from changes in the enteric nervous system.

Methods

Mice received an intravenous (IV) catheter and were randomized to chow (n = 5), IV PN (n = 6), or IV PN + bombesin (BBS, 15 μg/kg, 3×/d) (n = 6) for 5 d. Colons were removed and dissected to measure the length and circumference. Enteric neuronal density and neurotransmitter expression were determined by co-immunostaining whole-mount tissue with Hu and neuronal nitric oxide synthase (nNOS).

Results

The number of myenteric neurons expressing Hu and nNOS increased per unit length in the mid-colon during PN treatment compared with chow. This increase was abrogated by the addition of BBS to the PN regimen. However, the percentage of nNOS-expressing neurons was not significantly altered by PN. Morphometric analysis revealed a decrease in the length and circumference of the colon during PN administration that was partially normalized by supplementation of PN with BBS. A significant reduction in total fecal output was observed in PN animals compared with chow and was increased by mice receiving BBS in addition to PN.

Conclusions

PN causes a constriction of the bowel wall, reducing not only the length but also the circumference of the colon. These changes cause a condensation of enteric neurons but no difference in neurotransmitter expression. BBS supplementation partially restores the constriction and increases the fecal output during PN treatment compared with PN treatment alone.     

Colonic perforations after self-expandable metallic stenting: two case reports

The use of self-expandable metallic stents in colorectal stenoses, both benign and malignant, is a recently born treatment, quickly widespread because of its simplicity and therapeutic efficacy. It is particulary useful, like emergency temporany treatment, in malignant colonic obstruction; in these cases the temporary endoprosthesis positioning allows the intestinal transit and to overcame the emergengy phase. After patient conditions improvement, he can be operated and the endoprosthesis removed within operating specimen. In some particularly serious cases, when only a derivative intervention is mandatory because of the general conditions of the patient or the advanced stadium of the illness, stenting can also represent definitive palliative treatment. In fact, it allows contemporary resolution of the occlusion and of the physiopathologic alterations, with hospital cost reduction and a quality life imprevement for the patient thanks to the colestomy absence. In benign pathologies, self-expandable stents are used for a long time in the superior gastrointestinal and biliary tract; now stents have found employment also for the treatment of the post-operative fistula, intestinal diverticular occlusion and for the treatment of post-anastomotic or radiotherapy strictures. The Authors report two cases observed in emergency with complication determinated by positioning of colonic endoprosthesis for previous occlusive episode. The first case, a 56 year-old woman with a decubitus perforation occurred by stent, previously positioned with only palliative intent for a sigma-rectal metastatic cancer: in the second case, a 75 year-old man, the endoprosthesis had been positioned for a postoperative benign stricture of colorectal anastomosis for neoplasm: in this case the stent had determined a vescico-rectal fistula and after a new intestinal occlusion.     

IgA nephropathy associated with enteric fever

3 cases of enteric fever (2 paratyphoid and 1 typhoid) associated with IgA nephropathy were reported. Salmonella Vi antigen was demonstrated in the glomeruli. The clinical syndrome disappeared after enteric fever was treated. Possible pathogenesis was discussed relating this intestinal infection to IgA nephropathy.     

Gallbladder perforation: A rare complication of enteric fever

INTRODUCTION

Gallbladder perforation is a rare complication of acute calculous cholecystitis in adults. Perforation of gallbladder due to enteric fever is extremely rare condition. Pre-operative diagnosis is rarely made and mortality is high.

PRESENTATION OF CASE

We report a case of acalculous gallbladder perforation following enteric fever in a 14-year-old boy, who presented as acute abdomen and responded very well after emergency laparotomy and cholecystectomy.

DISCUSSION

Enteric fever is common in tropics and a common cause of bowel perforation. Acute cholecystitis is a rare complication of typhoid and gallbladder perforation is extremely rare complication. Ultrasound and CT lack specificity to detect gallbladder perforation. Diagnosis is usually made intra-operatively. Cholecystectomy is treatment of choice in such cases and provides good result.

CONCLUSION

Gallbladder perforation secondary to enteric fever requires a high degree of clinical suspicion. In typhoid endemic region, it should be considered as a differential diagnosis in patient presenting with a history of prolonged fever and signs of peritonitis. Early diagnosis and immediate surgical intervention are very important in reducing the morbidity and mortality. Cholecystectomy is the choice with a good outcome.     

A rare case report of enteric fever causing gallbladder perforation

Introduction and importanceEnteric fever is one of the major public health problems mainly in developing countries. Gallbladder perforation is very unusual. Enteric fever rarely causes gallbladder perforation. We report a case of gallbladder perforation due to enteric fever in an adult patient.Case presentationA 50-year-old female without any medical illness presented with a history of intermittent fever for two weeks and three days duration of severe abdominal pain. Upper abdominal tenderness and guarding were found in the abdominal examination. Ultrasonography showed thickening of the gallbladder wall and pericholecystic fluid collection. Magnetic resonance cholangiopancreatography revealed a distended gallbladder with sludge, diffuse wall thickening, and contained perforation with a mild amount of free fluid seen in the abdomen. With the diagnosis of type II gallbladder perforation, percutaneous ultrasonography-guided drainage was done. The culture of bile revealed positivity for Salmonella Typhi. Intra-venous antibiotic (ceftriaxone and gentamicin) was administered for 14 days. Four weeks later, cholecystectomy with peritoneal lavage was done. She was discharged on the 8th postoperative day.Clinical discussionPreoperative diagnosing of gallbladder perforation is challenging. The accurate treatment and precise timing of the surgery remain important. In most cases, cholecystectomy and abdominal lavage are adequate to treat gallbladder perforation.ConclusionsGallbladder perforation is a life-threatening surgical problem. The clinician should have a high index of awareness about this unusual surgical entity due to enteric fever and early diagnosis with prompt surgical intervention is necessary to improve patient outcomes.     

Laparoscopic surgical management of perforative peritonitis in enteric fever: a preliminary study

Early surgery in enteric perforation is the only accepted form of treatment in modem day medicine and gives excellent results. Exploratory laparotomy continues to be the mainstay of surgical treatment and several different procedures are recommended in literature. Between January 1998 and November 2001, we have successfully managed 6 consecutive cases of enteric perforation laparoscopically with complete resolution of the disease. There were 4 males and 2 females in our study. The mean time of presentation to us was 38 hours after the perforation (range 22 hours to 63 hours). The mean age was 32 years (range 28 years to 43 years). All patients presented with free air under the diaphragm. A laparoscopic approach was carried out through a 10 mm supraumbilical port and two 5 mm additional ports in the midline infraumbilical area and the left iliac fossa area. Simple one layer closure of the perforation was carried out with 2-0 silk intracorporeally and the peritoneal cavity was washed out and adequately drained. All perforations were localised to the terminal ileum and were single in number. The mean operating time was 54 minutes-(range 42 to 75 minutes). All patients received parenteral ofloxacin and metrogyl. Postoperative recovery was uneventful in all patients and there were no major complications. All patients were discharged from hospital by the 4th postoperative day. Follow up over a period of 12 to 16 months revealed all patients to be in normal health. We strongly recommend a first line laparoscopic approach in all patients with typhoid perforation; as it is a safe and effective method of managing such cases.