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

BACKGROUND: Ileal 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. METHODS: The 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. RESULTS: Of 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%. CONCLUSIONS: Enteric 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. METHODS: Patients 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. RESULTS: In 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. CONCLUSIONS: The 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.

BACKGROUND: Typhoid 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. METHODS: Between 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. RESULTS: Of 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. CONCLUSIONS: Although 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.

Ileal perforation by an odd foreign object.

Perforation of the gastrointestinal system by a foreign body is seldom observed in clinical practice; however, it has great importance because it is preventable and can usually be easily treated. In this case report, we present a young male patient, who mistakenly swallowed a foreign body and presented to the emergency service one day later with acute abdomen. The 23-year-old patient was diagnosed with acute appendicitis and underwent emergency laparotomy. During the operation, a plastic object that perforated the terminal ileum lumen and protruded into the abdominal cavity was identified. Along with appendectomy, the foreign body was removed and the ileum was repaired. The detailed history of the patient revealed that he had mistakenly swallowed something one day before the onset of abdominal pain. The patient was discharged on the postoperative seventh day following an uneventful course.

Multiple ileal perforations as late complications of electrical injury: A rare case report.

Introduction: Electric injury-induced intestinal perforation is one of rare and lethal complications. Direct injury and ischemic changes are the mechanism of intestinal perforation. Proper surgical and non-surgical management may increase the survival chance. Case presentation: A 21-year-old male was referred from rural hospital with history of electric burn injury two days before. On arrival, the patient started complaining bloating and abdominal x-ray revealed small intestine dilation. On fourth day post-event, the symptoms worsened and abdominal CT-scan revealed free peritoneal air. Exploratory laparotomy was performed, and two ileal perforations were found. Suturing of perforation and ileostomy were performed. Forequarter amputation of the right superior limb was performed on the seventh day post-event. On the third month, the ileostomy was closed. Conclusion: Intestinal perforation may be one of late complications of electrical injury in abdomen. Proper clinical evaluation and management helps in morbidity and mortality reduction.

Ileal Perforation and Psychosis in a 19-Year-Old Haemoglobin SC Patient-A Case Report.

Ileal perforation is a fatal surgical complication of typhoid fever. Acute psychosis occurring together with perforation presents a fatal outlook. This is made worse by these patients presenting late for appropriate intervention. A patient with sickle cell disease in addition to ileal perforation and psychosis presents a clinical picture the outcome of which is unpredictable. It could occasionally cause diagnostic dilemma and a great clinical challenge. Typhoid fever, a bacterial disease of low- income countries could be prevented by an improvement in socioeconomic conditions of the people. This will prevent or reduce to the barest minimum the occurrence of these fatal outcomes associated with its complications. This is the case report of a 19-year-old Haemoglobin SC (HbSC) with ileal perforation and acute psychosis.

Defunctioning ileostomy for typhoid ileal perforations: Out of the frying pan into the fire?

Typhoid ileal perforation (TIP) is a common surgical emergency in low-middle income countries (LMICs). Its high surgical morbidity and mortality is due to its often late presentation or diagnosis, the patient's malnutrition, severe peritoneal contamination and unavailability of intensive care in most peripheral hospitals. This prompted the philosophy of minimizing the crisis by avoiding any repair or anastomosis, limiting the surgery in these physiologically compromised patients and performing only a temporary defunctioning ileostomy (DI) which could then be closed 10-12 weeks later.

Ascending colon injury and ileal perforation due to blunt abdominal trauma: A case report.

A rare case of an ascending colon injury and ileal perforation in a 34-year-old male patient due to blunt abdominal trauma caused by a road traffic accident is reported in this study. This paper reports the clinical and imaging findings of seat belt syndrome. The seat belt syndrome primarily involves soft tissue injury; however, lacerations of the colon, small intestine, and mesentery have rarely been reported in the literature. However intestinal injuries, including bowel perforation and mesenteric injuries due to seat belt syndrome, must not be underestimated because they usually require emergency laparotomy because of accompanying peritonitis and hemorrhaging, and can be lethal if left untreated. Therefore, when an ascending mesocolon hematoma and free gas in the peritoneal cavity are present, gastrointestinal perforation due to seat belt syndrome should be suspected. In this case, gastrointestinal perforation was suspected based on the computed tomography findings, and emergency surgery was performed; the patient's course was uneventful without any postoperative complications. Early diagnosis and management are essential to prevent associated morbidity and mortality.

Co-occurrence of Tuberculous Meningitis and Intestinal Perforation in Abdominal Tuberculosis (TB): A Report of a Rare Case From Pakistan.

Tuberculosis (TB) remains a significant global health concern, with millions affected worldwide each year. Extrapulmonary TB, particularly involving the digestive tract and central nervous system, poses distinctive difficulties in both diagnosis and treatment. We report a case involving a 15-year-old girl with a history of intestinal TB on anti-tuberculous therapy who presented with symptoms suggestive of meningitis, along with abdominal pain and distension. Our initial suspicion was tuberculous meningitis, considering the underlining abdominal TB, which was later supported by cerebrospinal fluid analysis showing lymphocytic-predominant pleocytosis and positive acid-fast bacilli staining. Concurrently, the patient developed hemodynamic instability and severe abdominal pain, which on repeat X-rays of the abdomen showed air under the diaphragms, prompting surgical exploration and revealing multiple ileal perforations. Histopathological examination confirmed TB as the cause of perforation. This case highlights the diagnostic and therapeutic complexities of concurrent tuberculous meningitis and intestinal TB perforation. Early recognition and interdisciplinary management are crucial for optimal patient outcomes.

Ileal perforation due to migrated biliary stent: A case report.

Ileal perforation caused by the migration of a biliary stent is a rare complication that can occur during endoscopic stent placement for benign or malignant biliary tract diseases. The current study reports the case of a 45-year-old woman with a history of Endoscopic retrograde cholangiopancreatography (ERCP) in which a migrated biliary stent resulted in an ileal perforation.

A Rare Phenomenon of Stercoral Ileal Perforation in a Pregnant Woman.

Perforation peritonitis is one of the most common emergency presentations in Indian hospitals. Stercoral perforations are rare due to increased intraluminal pressure on the gut wall from impacted feces. This is associated with transmural necrosis. We present a 31-year-old pregnant woman who reported abdominal pain and vomiting at 34 weeks of gestation. The diagnosis was unclear from examination and imaging studies, and a provisional diagnosis of acute appendicitis was made. The patient underwent laparotomy and was found to have fecal contamination and multiple stercoral ileal perforations. The bowel segment was resected and exteriorized as a stoma.

Primary Gastrointestinal Diffuse Large B-cell Lymphoma Presenting as Ileal Perforation.

Diffuse large B-cell lymphoma (DLBCL) is the most common form of non-Hodgkin's lymphoma and can rarely present as a primary gastrointestinal malignancy. Primary gastrointestinal lymphoma (PGIL) is associated with a significant risk of perforation and peritonitis, with high rates of mortality. Here we describe a case of a newly diagnosed PGIL in a previously healthy 22-year-old male presenting for new-onset abdominal pain with diarrhea. Early hospital course was characterized by peritonitis and severe septic shock. Despite multiple surgical interventions and resuscitative efforts, the patient's condition continued to deteriorate until cardiac arrest and death on hospital day five. A diagnosis of DLBCL of the terminal ileum and cecum was made by pathology post-mortem. The prognosis for these patients can be improved through early intervention with chemotherapy regimens and surgical resection of the malignant tissue. This report highlights DLBCL as a rare cause of gastrointestinal perforation that can culminate in precipitous multiorgan failure and death.

Perforated ileum as the initial presentation of Crohn's disease, a case report.

INTRODUCTION: The perforation of the bowel as the first presentation of inflammatory bowel disease is a rare occurrence reported in about 0.15-3 % of the literature and is especially unusual in young patients <30 years of age. It is a serious event with most of the perforations occurring on the ileum. This article describes a unique case of a 20-year-old female patient who presented with perforated ileum due to Crohn's disease as an initial presentation operated at a private surgical center. CASE PRESENTATION: We present a case of a previously asymptomatic 21-year-old female presenting with intestinal perforation secondary to Crohn's disease for the first time. The patient presented with crampy abdominal pain and frequent bilious vomiting of 3 days duration. She also had a high-grade fever and abdominal distension. WBC was 24,000 and an abdominal CT scan showed perforation of the bowel consistent with Crohn's Disease. Ruling out other etiologies perforated viscous secondary to query Crohn's Disease was entertained and laparotomy revealed 2 × 2 cm perforation on the anti-mesenteric border of the terminal ileum. The perforated segment was resected primary anastomosis was performed. Following surgery, the patient was discharged symptom-free and linked to the Gastroenterology unit after a biopsy confirmed Crohn's disease. She was started on Prednisolone and Azathioprine exactly a month after her surgery. Her 6-month follow-up is smooth. CONCLUSION: Presentation of bowel perforation as an initial feature of Crohn's Disease is a rare phenomenon. Adequate resuscitation followed by emergency laparotomy with primary resection and anastomosis could be life-saving for a hemodynamically stable patient.

A fatal perforation of the distal ileum from an ingested fish bone: A case report.

INTRODUCTION AND IMPORTANCE: Foreign body-induced perforations of the ileum are rare consequences among adults. PRESENTATION OF CASE: This is a case report of a delayed presentation of an ileal perforation and concurrent faecal peritonitis presented as an acute abdomen, resultant from an ingested fishbone, which led to fatality despite urgent laparotomy. CLINICAL DISCUSSION: Perforations following ingested foreign bodies are frequently unanticipated clinically, and diagnosed during advanced imaging studies or surgical interventions. Endoscopy, laparoscopy, and laparotomy have been used during surgical management in reported cases; however, prior early identification is pivotal for good outcomes as delayed presentations and delayed diagnosis carry a poorer prognosis. CONCLUSION: Despite fish bones being frequent foreign bodies in the gastrointestinal tract and the majority causing no life-threatening adverse effects, they are the leading foreign bodies instigating gastrointestinal perforations. A high degree of suspicion is required when attending to patients with suspected gastrointestinal perforations and absent typical findings in routine imaging, where fish bones could be the aetiology.

Ileal lactobezoar in extreme premature infant complicated by intestinal perforation: A case report.

INTRODUCTION AND IMPORTANCE: Lactobezor is a rare complication that has been reported more in the stomach, however it may be located anywhere in the intestine. CASE REPORT: Reported here, is a case of ileal lactobezoar which was complicated by perforation and was mimicking necrotizing enterocolitis in presentation, ex preterm (26 weeks) male infant who presented at day of life 18th (2 days after BM fortification) with hemodynamic instability and intestinal perforation, which was diagnosed by Abdominal X-ray and Ultrasound necessitating urgent laparotomy. CLINICAL DISCUSSION: Laparotomy revealed an area of ileal perforation and an inspissated mass which was confirmed to be lactobezoar by pathology, ileostomy was performed. The baby had an acute postoperative status of hypovolemic shock which was managed clinically, then was restarted on feeds, and the stoma was reversed 9 weeks later. CONCLUSION: Lactobezoar, although rare, but numbers increased especially with the rise in numbers of extremely preterm infants worldwide, it most commonly presents later in life but in some cases, such as our case it may happen in 1st 2-3 weeks after birth and may cause significant complications as perforation making its differentiation from common GI problems in neonates as NEC more challenging.

One Year of Experience Managing Peritonitis Secondary to Gastrointestinal Perforation at a Tertiary Care Hospital: A Retrospective Analysis.

Introduction Peritonitis secondary to gastrointestinal perforation causes high morbidity and mortality rates in the emergency department with an immediate need for surgical intervention. Despite improved surgical management procedures, patients are still suffering from gastrointestinal leak causing peritonitis that demands surgical management by highly skilled surgeons in high-quality surgical units. Material and methods This paper presents one year of experience in the surgical treatment of gastrointestinal perforation-related peritonitis by surgeons in Lahore General Hospital, Lahore, Pakistan. Data was retrospectively collected from patient records and quantitatively analyzed. Involved patients developed peritonitis secondary to gastrointestinal perforation requiring surgical exploration and interventions in the emergency department between November 2020 and October 2021. Results One hundred and fifty-eight patients were involved; the mean age was 43.46 years. The number of males was 87 (55.06%). The patients mostly presented with generalized abdominal pain (57.6%). All the patients had perforation-related peritonitis, which was most prevalent in the ileum (62%). The most performed surgical intervention was loop ileostomy (36.71%). Compared to other published reports, the incidence rate of wound dehiscence in the hospital was relatively higher. Postoperatively, wound infection was low if the skin was left open (23.62%) compared to closed skin (38.7%). Patient outcomes were acceptable as the death rate was low (3.2%, 5/158). Conclusion Peritonitis caused by gastrointestinal perforation is associated with a high risk of morbidity that necessitates surgical exploration. Leaving skin wound open after the surgical intervention is recommended to decrease the incidence of wound infection and dehiscence.

Causes of Acute Peritonitis and Its Complication.

Introduction Peritonitis is a significant cause of morbidity and mortality in surgical settings. Coexisting premorbid illness and postoperative complications were found to be associated with death. This study aimed to analyze various etiologies that cause peritonitis and shed light on the factors responsible for unsatisfactory results. Method This longitudinal study included 309 patients above 12 years of age, of either gender, with confirmed diagnosis of peritonitis. Exploratory laparotomy was done to identify the cause of peritonitis. Patients were monitored postoperatively till their discharge or death for the development of complications. Results Our results showed that the most common cause of acute peritonitis was duodenal perforation (26.2%), followed by typhoid ileal perforation (24.2%) and ruptured appendix (16.8%). At least one complication was observed in 31% of the participants. The most common complication was dehydration (18.8%), followed by septicemia (11.3%) and paralytic ileus (6.4%). Ten (3.2%) patients died in the hospital. Conclusions Acute peritonitis is a serious surgical emergency caused by a number of diseases. Early surgical treatment along with antibiotics, followed by aggressive resuscitation can yield improved outcomes in patients with peritonitis.

Stillbirth as the primary manifestation of disseminated tuberculosis in a young immunocompetent mother with multiple perforations of the ileum.

Tuberculosis (TB), a significant cause of morbidity and mortality worldwide, is particularly relevant in low/middle-income countries like India, where the disease is endemic. The female reproductive system is very vulnerable to this infection with, the clinical presentation being utterly silent in most patients. Symptoms of TB in pregnancy may initially be attributed to the gravidity itself besides temporary concealment of associated weight loss by the normally occurring weight gain during the pregnancy. Untreated TB may cause pregnancy loss by either placental damage or direct harm to both the mother and child. We report a case of latent disseminated TB in a young immunocompetent female that was revealed in the postpartum state (after full-term stillbirth delivery at home) as 20 ileal perforations secondary to intestinal TB. Due to ongoing sepsis and delayed presentation to the hospital, the patient could not be salvaged despite the best possible efforts.

Feasibility and efficacy of ghost ileostomy in typhoid ileal perforations: A prospective observational study.

Loop ileostomy is commonly performed for typhoid ileal perforations as temporary faecal diversion. This is associated with several stoma-related complications and also requires further surgery for its closure. Thus, we were prompted to conduct a prospective observational study on the safety, feasibility and efficacy of ghost ileostomy in typhoid ileal perforations. After dealing with the perforation, a ghost ileostomy was performed in 10 selected patients with favourable circumstances; otherwise, a conventional loop ileostomy was performed in 19 patients. The two groups were comparable (p > 0.05) for morbidity and mortality except for stoma-related complications, seen only in the loop ileostomy group. Body weight was better preserved in the ghost ileostomy group. One patient in the ghost ileostomy group required conversion to loop ileostomy owing to signs of intra-peritoneal suture leak, without any detriment to outcome. Our study shows safety, feasibility and efficacy of ghost ileostomy in selected patients with typhoid ileal perforations, thus avoiding loop ileostomy in one-third of patients.

Morbidity and Mortality Associated with Typhoid Fever Among Hospitalized Patients in Hyderabad District, Pakistan, 2017-2018: Retrospective Record Review.

BACKGROUND: Hyderabad, Pakistan, was the first city to witness an outbreak of extensively drug resistant (XDR) typhoid fever. The outbreak strain is resistant to ampicillin, chloramphenicol, trimethoprim-sulfamethoxazole, fluoroquinolones, and third-generation cephalosporin, thus greatly limiting treatment options. However, despite over 5000 documented cases, information on mortality and morbidity has been limited. OBJECTIVE: To address the existing knowledge gap, this study aimed to assess the morbidity and mortality associated with XDR and non-XDR Salmonella serovar Typhi infections in Pakistan. METHODS: We reviewed the medical records of culture-confirmed typhoid cases in 5 hospitals in Hyderabad from October 1, 2016, to September 30, 2018. We recorded data on age, gender, onset of fever, physical examination, serological and microbiological test results, treatment before and during hospitalization, duration of hospitalization, complications, and deaths. RESULTS: A total of 1452 culture-confirmed typhoid cases, including 947 (66%) XDR typhoid cases and 505 (34%) non-XDR typhoid cases, were identified. Overall, ≥1 complications were reported in 360 (38%) patients with XDR typhoid and 89 (18%) patients with non-XDR typhoid (P<.001). Ileal perforation was the most commonly reported complication in both patients with XDR typhoid (n=210, 23%) and patients with non-XDR typhoid (n=71, 14%) (P<.001). Overall, mortality was documented among 17 (1.8%) patients with XDR S Typhi infections and 3 (0.6%) patients with non-XDR S Typhi infections (P=.06). CONCLUSIONS: As this first XDR typhoid outbreak continues to spread, the increased duration of illness before hospitalization and increased rate of complications have important implications for clinical care and medical costs and heighten the importance of prevention and control measures.