Typhoid Fever

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enteric fever, typhoid fever, surgical complications

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  • 1.TYPHOID Surgical Complications *DR. MANSOOR KHAN 28 thOct, 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-systemicillness caused primarily bySalmonella typhiandparatyphi 4. Typhoid---ancient GreekTyphos, smokeor cloud that was believed to cause disease or madness 5. S. typhi,amajor human pathogen for thousands of years , thriving in conditions ofpoor sanitation ,crowding , andsocial chaos 6. 430426 B.C. Killed 1/3 of thepopulation ofAthens , including their leaderPericles . Thepower shifted fromAthens to Sparta .2006 study detected DNA sequencessimilar salmonella 7. Antonius Musa ARoman physicianwho achieved fame by treating theemperor 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 roughly21.6 millionpeople each year * International Estimate Ramsden AE, Mota LJ, Mnter S, Shorte SL, Holden DW.The SPI-2 type III secretion system restricts motility of Salmonella-containing vacuoles.Cell 14. Kills200,000people each year * International Estimate Ramsden AE, Mota LJ, Mnter S, Shorte SL, Holden DW.The SPI-2 type III secretion system restricts motility of Salmonella-containing vacuoles.Cell 15. 62%of these occurring inAsiaand35%in Africa * International Estimate * Taylor TE, Strickland GT. Malaria. In: Strickland GT, ed. Hunters Tropical Medicine and Emerging Infectious Diseases. 8th ed. Philadelphia: WB Saunders, 2000:614-43. 16. Highest inPakistan & Indiain Asian countries (451.7 per 100,000)* WHO Estimate *Bull World Health Organvol.86no.4GenebraApr.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 20. 21. Bacteriaare better scientists than we are War of survivalthey are working out very hard 22. RISK FACTORS 23. S. typhiare able to survive astomach pH as low as1.5 .Antacids , (H2 blockers), PPIs,gastrectomy, facilitateS typhiinfection 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 periodis 7-14 days 26. FIRST WEEK TEMPERATURE PATTERN 27. Diffuseabdominal pain , Inflamed Peyer patches narrow the lumen-- Constipation . Dry cough, dull frontalheadache , delirium, increasingly Stupor & malaiseFIRST 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, Softsplenomegaly ,Relative bradycardia&dicrotic pulse (double beat, the second beatweaker than the first) SECOND WEEK 30. Patient may descend intothetyphoid state- --apathy,confusion, and even psychosis THIRD WEEK TYPHOID STATE 31. Necrotic Peyer patches, bowel perforation, Peritonitis, intestinal hemorrhagemay cause death THIRD WEEK Week of complications 32. Fever, mental state,and abdominal distensionslowly improve over a few days, complications may still occurin 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 conditionsSingh S, Pandya Y, Rathod J, Trivedi S. Bilateral breast abscess: A rare complication of enteric fever. Indian J Med Microbiol [serial online] 2009 [cited2009 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 withtyphoid fever experiencethis complicationDS00538 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, Pages1512-1515 Published Online:8Dec2005 40. Ileum especiallydistal ileum , jejunum usually doesnot perforate in typhoid, usually happens in thethird week 41. MECHANISM OF INTESTINAL PERFORATION Intestinal peyers patches 42. 2 or 3 weeks hx of disease,withsuddenly worsening ofpain&general conditions , Tenderness starts in his right lowerquadrant, spreads and eventuallybecomes generalized, Guarding ,(seldom the board-like rigidity) Erect film, shows gasUnder diaphragm (50% positive) lateral decubitus film, shows gasunder his abdominal wall The bradycardia and leucopenia of typhoid may occasionally mask the tachycardia and leucocytosis of peritonitis PRESENTATIN PERFORATION 43. PATIENT PERFORATION 44. Ifperitonitis 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,Monitorabdominal tenderness, pulse, temperature, white blood count.If any of these rise, suspect that peritonitis is extending, so take an erectX-ray film of his abdomen CONSERVATIVE MANAGEMENT 46. MDR-area MDR+NAR-area MEDICATION TREATMENT WHO RECOMMENDATIONS 47. Do not forgetto coveranaerobesandgram negativebacteria along with salmonella 48. Operateas early as possible , Doas 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 54. POSTOPERATIVELY

  • Fever usually subsides in 4 or 5 days
  • Nourish patient as early as possible
  • ICU care and monitoring
  • Continue chemotherapy 14days

55. S P E C I M E N S John Hunter (1728-1793) 56. INTESTINAL HEMORRHAGE Occurs in 10-20per cent of the cases 57. Intestinal bleeding is often marked by asudden drop in blood pressureand shock, followed bythe appearance ofblood in stool Hemorrhagepresentation 58. replace the blood loses.Bleeding usually stopsspontaneously 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 therapyis the recommended treatment for Typhoid AAC Acute Acalculous Cholecystitis TYPHOID 64. Chronic Cholecystitis (Carriers) TYPHOID Excretes bacteria in stools formore > 1 year1-4%of non-treated infected patients become chronic carriers Patients withcholelithiasis, 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, sheinfected 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 70. 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 sewagetreatmentcan eliminate typhoid Prompt anntibiotictherapy can save manylivestake it a serious job Severe vomiting,diarrhoea & abdominaldistension--- complicated,admit them & give IVantibiotics and supportPrognosis of complications depends on the time-lapseb/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 76. w w w . s l i d e s h a r e . c o m