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134]
Original Article
INTRODUCTION
ABSTRACT
Background: Intestinal perforation resulting from
complicated typhoid fever still causes high morbidity
and mortality. The purpose of the present study is to
evaluate the outcome of its surgical management in
Nigerian children. Materials and Methods: Emergency
laparotomy and repair of the ileum was performed on
46 children with typhoid ileal perforation at the Federal
Medical Centre (FMC), Azare, Nigeria, between January
2004December 2008. This was followed by copious
peritoneal lavage with warm normal saline and mass
closure of the abdomen. Results: There were 28
(60.86%) boys and 18 (39.13%) girls, with a mean age
of 9.5 3.22 (range, 15 months15 years). Abdominal
pain (45), fever (44), and abdominal distention (36) were
the most common presenting symptoms and majority
of the patients (36) perforated within 14 days of illness.
Solitary ileal perforations were the most common
pathology, found in 31 (67.4%) cases. Simple closure
of the perforations after debridement of the edges was
the most frequent operative procedure performed. A
total of 21 patients had one or more complications which
included wound infection (21), postoperative fever (16),
and wound dehiscence (6). Postoperative anaemia
was a problem in 23 (50%) patients. The mortality rate
was (13) 28.3%. The mean duration of hospital stay for
survivors was 22.9 12.3 (range, 646 days). This was
not significantly affected by the location or number of
perforations on the ileum. Conclusions: The clinical
course of typhoid ileal perforation may be different for
the very young. The typically high rate of complications
can be reduced if operation is undertaken earlier.
Solitary ileal perforations can be managed safely with
simple closure.
Key words: Children, management outcome, typhoid
ileal perforation
PMID: *******
DOI: 10.4103/0189-6725.59351
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RESULTS
There were 46 children [28 (60.8%) boys and 18 (39.1%)
girls], with intraoperative diagnosis of typhoid ileal
perforation during the study period. Their mean age was
9.5 3.22 (range, 15 months- 15 years); and male: female
ratio was 1.5:1. Also, 36 (76.1%) patients were between
the age range of 915 years [Table 1]. There were 4
(8.7%) children below the age of five years. Almost all
the patients presented with abdominal pain, fever, and
features of peritonitis. The mean time lapse between
onset of symptoms of perforation and presentation to
hospital was 72.44 9.33 hours, (range, 24168). A
total of 44 (95.6%) patients had fever, 36 (78.3%) had
abdominal distention, 25 (54.3%) had vomiting, and
23 (50%) had constipation [Table 2]. Of the 41 patients
recorded, 21 (51.2%) perforated within the first seven
days of illness, 15 (36.6%) within the second week,
and 5 (12.2%) within the third week of illness. Plain
chest and abdominal radiographs were available for 31
(67.4%) patients with 16 (51.6%) showing free gas under
the diaphragm. The main electrolyte derangements were
hypokalaemia and raised serum urea in 13 (28.3%)
patients respectively. The packed cell volume (PCV)
was lower than 30% in 37 (80.4%) children. The widal
test was done in only 5 (10.8%) patients with the titre
higher than 1:160 in all of them. Blood cultures were
not done in any of the patients. A total of 24 (52.2%)
patients had surgery within 24 hours of presentation
to hospital and the rest 16 (34.7%) were operated after
24 hours of admission. The mean time from admission
to laparotomy was 9.4 hours (range, 624). The main
resuscitative measures in all the patients involved
Males
Females
Frequency (%)
4
4
11
10
29 (63.04)
0
3
6
8
17 (37.00)
4 (8.7)
7 (15.2)
17 (37)
18 (39.1)
46 (100)
Six hundred and seventy children were treated for typhoid fever, giving a perforation
rate of 6.8%.
Features (%)
45 (97.8)
44 (95.7)
42 (91.3)
36 (78.3)
25 (54.3)
23 (50)
12 (26.1)
Figure 1: Typical single perforation of the terminal ileum due to typhoid fever
in a 10-year-old girl. Note the antemesenteric location and faecal peritonitis
Frequency (%)
31 (67.4)
5 (10.8)
5 (10.8)
3 (6.5)
1 (2.2)
1 (2.2)
87 (100)
NB: There were a total of 87 ileal perforations. The highest number of perforations in
a single child was 14. The overall mortality rate was 28.3%.
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DISCUSSION
Typhoid ileal perforation is frequently seen among
children in our environment. Over this study period,
children aged 15 years and younger constituted 55.4%
of all cases. This is in keeping with earlier reports
from Nigeria where the paediatric age group accounted
for more than half the cases of typhoid intestinal
perforation. [5,6] In one of the report from Western
Nigeria[7] and India,[11] however, typhoid perforation
was the most common in the age group of 2130
years. There was a slight male preponderance (a male
female ratio of 1.7:1); similar to previous series.[6,8] The
prognosis of typhoid ileal perforation still remains
poor, with an overall mortality in this study of 28.3%,
in keeping with most previously reported series in the
tropical environment, including West Africa.[16] We
found, as previously reported, that the perforations are
the most common in the terminal ileum and survivors
were faced with wound infection and high rates of
wound dehiscence and enterocutaneous fistulae.[9]
Frequency (%)
21 (45.6)
16 (34.7)
9 (19.7)
6 (13)
4 (8.7)
4 (8.7)
3 (6.5)
1 (2.2)
11
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ACKNOWLEDGEMENTS
We thank all the consultants and resident doctors of the
Department of Surgery, Federal Medical Centre, Azare for their
cooperation during the period of this study. We appreciate
the contribution of the Nurses on the Surgical and Paediatric
Surgical wards of the Hospital and the Medical records staff
for extracting the folders.
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