A patient was admitted in our facility since 9th April 2011 at 8.00 pm for severe abdominal pains and some degree of abdominal distension. He had passed stool the day before.
On admission the intestinal sounds were sluggish but still present.
Overnight the patient has been fasted and NGT (naso-gastric-tube) inserted. Also a flatus tube has been inserted through the rectum. He has been put on iv CAF (Chloramphenicol) and iv Metronidazole. He has been rehydrated with Hartman’s solution.
Today in the morning he presented with profuse sweating, severe abdominal pains, abdominal distension (much increased compared to last night), total absence of intestinal sounds, some fever and rapid pulse rate.
The U/S has shown important ascites and intestinal loops floating in it, with no signs of peristalsis: my suspicion was of paralytic ileus secondary to intestinal perforation, probably due to typhoid fever. Widal test was actually positive both for antigen O and H at a titer of 1:320. The WBCs were elevated at 15,000 per ml, of which 90% were granulocytes. Electrolytes fortunately were in range.
In this moment we have no visiting surgeon and no visiting anesthetist from Italy.
The operation the patient needed was therefore beyond our surgical possibilities.
We have hence transferred the patient to Meru District Hospital for further management. If Dr Pietro and the Italian Anesthetist were already here, probably we would have managed the condition.
It is our hope to be able to plan for coverage with surgeons and anesthetists from abroad the entire year, so that even the emergency intestinal operations (which cannot be planned or postponed) may be performed in Cottolengo Mission Hospital.
Typhoid fever is very common in our setting and it can be a very serious medical condition with protean and aspecific symptoms which can mimic either a severe malaria or even a meningitis.
The main surgical complication of Typhoid we observe here in Chaaria, is actually the intestinal perforation, which normally happens in the 3rd week of the disease.
Perforation is due to strong inflammation (mediated by macrophages) in the intestinal lymph follicles, particularly the Peyer’s patches in the ileum.
The strong inflammatory response in the Peyer’s patches may lead to hyperplasia, necrosis and ulceration, if the inflammation doesn’t resolve.
Involvement of the blood vessels may cause bleeding and, if the whole thickness of the bowel is involved, perforation follows.
The patient becomes rapidly toxemic, and paralytic ileus ensues very quickly. Urgent and timely referral for surgical management is paramount by day and by night.
Dr Bro Beppe Gaido
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