Nontraumatic Ileal Perforation Research Articles

Typhoid intestinal perforation in Francophone Africa, a scoping review.

Typhoid intestinal perforation (TIP) is a leading cause of peritonitis and indication for emergency surgery in Africa, with reported mortality rates up to 30% in pediatric patients. Currently, data on TIP in Western databases are primarily from countries that speak English, likely due to non-English publication and citation biases. Despite the high burden of infectious diseases in Francophone Africa, data from these countries regarding TIP remain limited. This study aims to highlight the incidence and morbidity of TIP in Francophone African countries using an extended search algorithm. We conducted a scoping review using the PubMed, EMBASE, and SCOPUS databases with the keywords "peritonitis", "non-traumatic ileal perforation", and "typhoid" in Francophone African countries. Additionally, we contacted surgeons in Africa and concurrently used citation chasing to obtain data not found in western databases. In total, 32 studies from 12 countries were identified and included in this review. A total of 22 publications were in French. Patient median age was 20 years and TIP caused a median of 35% of acute peritonitis cases. Mortality rates ranged from 6-37% (median: 16%). Rate of complications ranged from 15-92% (median: 46%). Ileostomy creation as a treatment for TIP varied between hospitals (0-79%), with the highest rates reported in Niger. In Francophone Africa, TIP is associated with high morbidity and mortality, most commonly in children and young adults. Interventions, including improved sanitation and the introduction of typhoid conjugate vaccines into routine vaccination programs, have the potential to significantly decrease typhoid fever and its complications.

Incidence of typhoid and paratyphoid fever in Bangladesh, Nepal, and Pakistan: results of the Surveillance for Enteric Fever in Asia Project

SummaryBackgroundPrecise enteric fever disease burden data are needed to inform prevention and control measures, including the use of newly available typhoid vaccines. We established the Surveillance for Enteric Fever in Asia Project (SEAP) to inform these strategies.MethodsFrom September, 2016, to September, 2019, we conducted prospective clinical surveillance for Salmonella enterica serotype Typhi (S Typhi) and Paratyphi (S Paratyphi) A, B, and C at health facilities in predetermined catchment areas in Dhaka, Bangladesh; Kathmandu and Kavrepalanchok, Nepal; and Karachi, Pakistan. Patients eligible for inclusion were outpatients with 3 or more consecutive days of fever in the last 7 days; inpatients with suspected or confirmed enteric fever; patients with blood culture-confirmed enteric fever from the hospital laboratories not captured by inpatient or outpatient enrolment and cases from the laboratory network; and patients with non-traumatic ileal perforation under surgical care. We used a hybrid surveillance model, pairing facility-based blood culture surveillance with community surveys of health-care use. Blood cultures were performed for enrolled patients. We calculated overall and age-specific typhoid and paratyphoid incidence estimates for each study site. Adjusted estimates accounted for the sensitivity of blood culture, the proportion of eligible individuals who consented and provided blood, the probability of care-seeking at a study facility, and the influence of wealth and education on care-seeking. We additionally calculated incidence of hospitalisation due to typhoid and paratyphoid.FindingsA total of 34 747 patients were enrolled across 23 facilitates (six tertiary hospitals, surgical wards of two additional hospitals, and 15 laboratory network sites) during the study period. Of the 34 303 blood cultures performed on enrolled patients, 8705 (26%) were positive for typhoidal Salmonella. Adjusted incidence rates of enteric fever considered patients in the six tertiary hospitals. Adjusted incidence of S Typhi, expressed per 100 000 person-years, was 913 (95% CI 765–1095) in Dhaka. In Nepal, the adjusted typhoid incidence rates were 330 (230–480) in Kathmandu and 268 (202–362) in Kavrepalanchok. In Pakistan, the adjusted incidence rates per hospital site were 176 (144–216) and 103 (85–126). The adjusted incidence rates of paratyphoid (of which all included cases were due to S Paratyphi A) were 128 (107–154) in Bangladesh, 46 (34–62) and 81 (56–118) in the Nepal sites, and 23 (19–29) and 1 (1–1) in the Pakistan sites. Adjusted incidence of hospitalisation was high across sites, and overall, 2804 (32%) of 8705 patients with blood culture-confirmed enteric fever were hospitalised.InterpretationAcross diverse communities in three south Asian countries, adjusted incidence exceeded the threshold for “high burden” of enteric fever (100 per 100 000 person-years). Incidence was highest among children, although age patterns differed across sites. The substantial disease burden identified highlights the need for control measures, including improvements to water and sanitation infrastructure and the implementation of typhoid vaccines.FundingBill & Melinda Gates Foundation.

Ileal Perforation and Enteric Fever: Implications for Burden of Disease Estimation.

BackgroundIleal perforation occurs in about 1% of enteric fevers as a complication, with a case fatality risk (CFR) of 20%–30% in the early 1990s that decreased to 15.4% in 2011 in South East Asia. We report nontraumatic ileal perforations and its associated CFR from a 2-year prospective enteric fever surveillance across India.MethodsThe Surveillance for Enteric Fever in India (SEFI) project established a multitiered surveillance system for enteric fever between December 2017 and March 2020. Nontraumatic ileal perforations were surveilled at 8 tertiary care and 6 secondary care hospitals and classified according to etiology.ResultsOf the 158 nontraumatic ileal perforation cases identified,126 were consented and enrolled. Enteric fever (34.7%), tuberculosis (19.0%), malignancy (5.8%), and perforation of Meckel diverticulum (4.9%) were the common etiology. In those with enteric fever ileal perforation, the CFR was 7.1%.ConclusionsEnteric fever remains the most common cause of nontraumatic ileal perforation in India, followed by tuberculosis. Better modalities of establishing etiology are required to classify the illness, and frame management guidelines and preventive measures. CFR data are critical for comprehensive disease burden estimation and policymaking.

Cost of Illness Due to Severe Enteric Fever in India.

Background Lack of robust data on economic burden due to enteric fever in India has made decision making on typhoid vaccination a challenge. Surveillance for Enteric Fever network was established to address gaps in typhoid disease and economic burden.MethodsPatients hospitalized with blood culture-confirmed enteric fever and nontraumatic ileal perforation were identified at 14 hospitals. These sites represent urban referral hospitals (tier 3) and smaller hospitals in urban slums, remote rural, and tribal settings (tier 2). Cost of illness and productivity loss data from onset to 28 days after discharge from hospital were collected using a structured questionnaire. The direct and indirect costs of an illness episode were analyzed by type of setting.ResultsIn total, 274 patients from tier 2 surveillance, 891 patients from tier 3 surveillance, and 110 ileal perforation patients provided the cost of illness data. The mean direct cost of severe enteric fever was US$119.1 (95% confidence interval [CI], US$85.8–152.4) in tier 2 and US$405.7 (95% CI, 366.9–444.4) in tier 3; 16.9% of patients in tier 3 experienced catastrophic expenditure.ConclusionsThe cost of treating enteric fever is considerable and likely to increase with emerging antimicrobial resistance. Equitable preventive strategies are urgently needed.

Burden of Ileal Perforations Among Surgical Patients Admitted in Tertiary Care Hospitals of Three Asian countries: Surveillance of Enteric Fever in Asia Project (SEAP), September 2016–September 2019

BackgroundTyphoid fever is caused by Salmonella enterica subspecies enterica serovar Typhi (S. Typhi) and can lead to systemic illness and complications. We aimed to characterize typhoid-related ileal perforation in the context of the population-based Surveillance of Enteric Fever in Asia Project (SEAP) in Bangladesh, Nepal and Pakistan.MethodsBetween September 2016 and September 2019, all cases of nontraumatic ileal perforation with a clinical diagnosis of typhoid were enrolled from 4 tertiary care hospitals in Karachi, 2 pediatric hospitals in Bangladesh, and 2 hospitals in Nepal. Sociodemographic data were collected from patients or their caregivers, and clinical and outcome data were retrieved from medical records. Tissue samples were collected for histopathology and blood cultures where available.ResultsOf the 249 enrolled cases, 2 from Bangladesh, 5 from Nepal and 242 from Pakistan. In Pakistan, most of the cases were in the 0–15 (117/242; 48%) and 16–30 (89/242; 37%) age groups. In all countries, males were most affected: Pakistan 74.9% (180/242), Nepal 80% (4/5), and Bangladesh 100% (2/2). Blood culture was done on 76 cases; 8 (11%) were positive for S. Typhi, and all were extensively drug resistant (XDR) S. Typhi. Tissue cultures was done on 86 patients; 3 (3%) were positive for S. Typhi, and all were XDR S. Typhi, out of 86 samples tested for histopathology 4 (5%) revealed ileal perforation with necrosis. Culture or histopathology confirmed total 15 (11%) enteric fever cases with ileal perforation are similar to the clinically diagnosed cases. There were 16/242 (7%) deaths from Pakistan. Cases of ileal perforation who survived were more likely to have sought care before visiting the sentinel hospital (P = .009), visited any hospital for treatment (P = .013) compared to those who survived.ConclusionsAlthough surveillance differed substantially by country, one reason for the higher number of ileal perforation cases in Pakistan could be the circulation of XDR strain of S. Typhi in Karachi.

The benefits of protective defunctioning ileostomy in ileal perforation surgery

Background: Perforation of bowel, particularly ileal perforation, is a significant emergency surgical problem in developing and underdeveloped nations and usually associated with high morbidity and mortality. The study is focussed on evaluating the impact of protective ileostomy in ileal perforation and to compare its outcome in term of post operative complication, hospital stay, psychological impact and mortality with primary surgery without ileostomy and observe its effect on prognosis of patient as a whole. Aim of the study we compared two modalities of treatment, primary surgery without ileostomy v/s primary surgery with protective defunctioning ileostomy with respect to post operative complications, duration of hospital stay, morbidity, mortality and psychological impact. Methods: We studied 50 patients of ileal perforation (diagnosed per-operatively) admitted to tertiary level hospital and operated upon for laparotomy. Patients were divided in 2 groups: Group A = Protective defunctioning ileostomy along with primary surgery, and Group B = Primary surgery alone. Primary surgery includes primary closure of perforation or resection and end to end anastomosis.Results: The commonest cause of non-traumatic ileal perforation was typhoid (52%) followed by non specific, tuberculosis and diverticulitis. Different types of operative procedures were performed. In Group A, total no. of dreaded complications like faecal fistula was 1 while in Group B, 10 patients developed faecal fistula. Other complications like wound infection and wound dehiscence were 28% in Group A while 96% in Group B. Overall mortality rate was 24% with 12% mortality in group A and 36% in group B. Mean hospital stay in Group A patient was 12.640±5.75 days (1-23 days) and those of group B was 23.760±16.04 days (5 - 59 days). Conclusions: Construction of protective defunctioning ileostomy in case of distal ileal perforation repair or anastomosis greatly reduces the dreaded complication and mortality in comparison to perforation repair or anastomosis without protective ileostomy. Although it is associated with ileostomy related complications, but they are only temporary and obviously no more than the price of life saved.

Prognostic Factors of Non-Traumatic Small Bowel Perforation Peritonitis: A Multicenter Study in North Benin

Objective: Identify the factors affecting the non-traumatic intestinal perforations peritonitis outcome. Methods: This was a retrospective study over a period of 30 months (1st January 2014 – 30th June 2016), which took place in four hospitals in northern Benin, including three district hospitals and one teaching hospital. The study population consisted of patients operated for generalized acute peritonitis. The inclusion criteria were: peroperative confirmation of the non-traumatic ileal perforation and the existence of a complete medical record in relation to the variables studied. Results: We collected 121 cases of non-traumatic ileal perforation peritonitis with a total of 447 cases of generalized acute peritonitis; the non traumatic ileal perforation peritonitis frequency was 27.1%. Ninety-nine files met the inclusion criteria. The mean age was 17 ± 12 years with extremes of 2 and 60 years. The sex ratio was 2.4. The predictive factors were: age (p 0.00), consultation time (p 0.03), surgical time (p 0.02), amount of peritoneal fluid (p 0.001), perforation number (p 0.0009), surgical technique (p 0.0003) and postoperative complications such as digestive fistula (p 0.001) and postoperative peritonitis (p 0.04). Conclusions: At the end of our study, the factors of bad prognosis identified were the age, the time of consultation, the time of surgery, the quantity of peritoneal fluid. Some postoperative complications may cause death.

A rare presentation of ileal perforation due to local iron toxicity

Ileal perforation peritonitis is a frequently encountered surgical emergency in developing countries. In contrast to Western countries where lower gastrointestinal (GI) tract perforations predominate, upper GI tract perforations attribute to the majority of cases in India. Spontaneous ileal perforation remains a dreaded surgical condition in developing countries. Typhoid fever is the predominant cause of nontraumatic ileal perforation, while other causes include tuberculosis, nonspecific inflammation, obstruction, radiation enteritis, and Crohn's disease. Iron tablets, in case of toxicities, are notorious for causing erosions of the gastric mucosa due to their corrosive effect leading to perforations. The incidence of these, however, is few and far between. However, iron tablets causing erosions as a cause of ileal perforation is virtually unheard of. Literature suggests the possible perforations due to iron toxicity to be in the upper GI tract, namely stomach and duodenum, reflecting the sites of absorption. In this case report, we present a patient with an ileal perforation following acute ingestion of iron tablets. We suspect that this is probably either due to the sheer number of tablets, leading to a reduced absorption, or the fact that it may be enteric coated, which may explain the passage through the upper GI tract undigested. There are no studies to the authors' knowledge that explain such a finding. Thus, there is no consensus on the total amount of iron needed or the minimum time exposed to the toxic agent to produce such a finding.

Prise En Charge Des Péritonites Aiguës Dans Un Hôpital De District En Afrique Sub-saharienne : Cas Du Bénin

Introduction: Peritonitis remains a public health problem in Africa. We aim to describe the epidemiological, etiological and therapeutic aspects of acute peritonitis in a district hospital in Sub Saharan Africa. Methods: This was a descriptive study with prospective data collection over a period of 15 months from May 1 st 2015 to July 31st 2016 in Bembereke district hospital. It has taken into account all the patients managed in the general surgery department for acute generalized peritonitis that has been confirmed at laparotomy. Results: Fifty-three patients, 38 men (71.7 %) and 15 women (28.3 %) had been registered. The average age of the patients was 19.8 ± 16.9 years. The main etiologies were: non-traumatic ileal perforation from typhoid infection 52.8%; perforated gastric or duodenal ulcer 17%; complicated appendicitis and abdominal traumas 11.3% each one. Twenty nine patients (54.7%) have been operated by a surgeon and the 24 remaining (45.3%) by a general practitioner with surgical skills. Twenty one patients (39.6%) had postoperative complications of which 11 cases of parietal suppurations (52.4%). The mortality rate was 11.3%. The mean hospital stay was 22.5 ± 4 days. Conclusion: In northern-Benin, peritonitis remains dominated by the complications of typhoid fever. The mortality rate remains high. Prevention requires good hygiene and awareness of early consultations.

Wound Outcome Following Primary and Delayed Primary Skin Closure Techniques After Laparotomy for Non-Traumatic Ileal Perforation: a Randomized Clinical Trial.

To study the effect of primary and delayed primary closure of skin incision on wound outcome in patients with non-traumatic ileal perforation, 68 patients of ileal perforation were studied in a prospective randomized clinical trial. Patients fulfilling inclusion criteria were divided into ileostomy and non-ileostomy groups, both of which were then randomized into two subgroups each depending on whether skin was closed primarily or in a delayed primary manner. Wound infection and dehiscence were the main outcome parameters studied. The data collected was analyzed using appropriate statistical tools taking significant p value at 5%. Most patients were 21-30years of age. Male:female ratio was 3.2:1. The overall incidence of wound infection was 63%. Wound infection was strongly associated with the incidence of superficial wound dehiscence and total wound dehiscence that were 11.76 and 47%, respectively. Mortality was 10.3%. Methodology of wound closure has no significant impact on incidence of wound infection, wound dehiscence, and mortality, although the onset of wound complications is significantly delayed with delayed primary closure of the skin.

Non-traumatic ileal perforation: a retrospective study.

Objective:To determine clinical features, operative findings and post-operative complications in patients operated for non-traumatic ileal perforation and to discuss the role of typhoid vaccination.Materials and Methods:A retrospective study was carried out from 2009-2010. Seven patients were admitted through casualty as cases of acute abdomen. Underlying conditions were typhoid ulcers (4 patients) and non-specific etiology (3 patients). Diagnosis was made on clinical grounds, laboratory investigations, radiology and operative findings. Exploratory laporotomy was done. Different variables studied post-operatively were wound infection, residual abscess, recurrence and delayed post-operative complications.Results:Tenderness, distension and rigidity were found in maximum patients. Gases under diaphragm and air fluid levels were common radiological findings. However, widal test and blood culture for S. typhi was positive in four patients. Six patients had single perforation and one patient had two perforations, all being on antimesentric border of ileum. Maximum patients had peritoneal collection of less than 1000 ml. In five patients simple closure of perforation was done and in remaining two resection with end to side ileotransverse anatomosis was required. Wound infection and residual intraabdominal abscess were found in one patient each.Conclusion:Management criteria remain same in typhoid and non-specific perforations. Commonest cause of ileal perforation is typhoid fever in our country, so immunization against typhoid beyond 18 years of age is recommended.