A 28 year old patient, a chronic alcoholic came with complaints of severe abdomen pain of 5 days duration and recurrent vomiting. An erect Xray of Abdomen showed Air under diaphragm. He gave a history of binge drinking 7 days back, which made us suspect a Gastric/ Duodenal Perforation. A separate history of fever or malaise before onset of abdominal pain was unclear.

Laparotomy was performed by midline incision. On inspecting, we found two perforations in ileum about 15 cm apart, the distal one was about 30 cm from ileocaecal junction. The approximate diameter of proximal perforation was 0.5 cm and the distal perforation was 2 cm. Both the perforations were on the antimesenteric aspect of ileum. 

The abdominal contamination was moderate and there were pus flakes dispersed in subhepatic space and right iliac fossa, these were taken out as much as possible. The ileal loop was isolated and a thorough abdominal wash with warm saline was given. Finally a Segmental Ileal Resection was performed followed by a Hand Sewn End to End Anastomosis. Drains were inserted into both Right and Left Iliac Fossae. Post operatively, typhoid fever diagnosis was verified serologically.

Patients was put on a third generation cephalosporin along with other supportive and symptomatic treatment. Condition of the patient improved and he passed stools on 5th postoperative day.

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A CASE OF TRAUMATIC ILEAL PERFORATION AND MESENTERIC TEAR
http://www.worldsurgeryforum.net/2016/05/a-case-of-traumatic-ileal-perforation.html

ILEAL PERFORATION DUE TO TYPHOID FEVER
http://www.worldsurgeryforum.net/2016/04/ileal-perforation-due-to-typhoid-fever.html

3/12/2018 11:07:00 PM

Ileal perforation due to Typhoid fever

  Clinical History

• A 29-year-old male patient was admitted with complaints of fever for 2 weeks, abdominal pain and vomiting for 2 days, abdominal distension for 2 days, and not passing stools and flatus for 1 day. 
• He did not receive any treatment during 2 weeks. There was no history of long term abdominal pain and analgesic abuse, but patient was a chronic smoker and alcoholic.
• There was no history of previous similar complaints
• On examination, there was a mild distinction. Guarding and board like rigidity was present.
• Bowel sounds were not heard. PR revealed empty rectum.
• ESR was elevated, WBC count was 15200
• Xray showed air under diaphragm
• Hence a diagnosis of hollow viscous perforation was made.
• Later, widal test was also found to be positive 

Pathogenesis 

Pathogenesis of typhoid intestinal perforations

• Peyer patches become hyperplastic and subsequently ulcerate, with complications of hemorrhage or perforation

Differential Diagnosis 

• Includes appendicitis, appendicular perforation, perforated peptic ulcer, strangulated gut with volvulus, and necrotizing amoebic colitis 

Management 

• Simple closure of the perforation is the treatment of choice and was done in this case.
• With multiple perforations, which occur in about 25% of patients, resection with primary anastomosis or exteriorization of the intestinal loops may be required 

References

• Sabiston Text Book Of Surgery
  
• http://www.meb.uni-bonn.de/dtc/primsurg/docbook/html/x11177.html

4/11/2016 12:30:00 AM