Acute Peritonitis Generalized by Typhoid Perforation at Kankan Regional Hospital

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Japanese Journal of Gastroenterology and Hepatology
Volume 5ISSN 2435-1210Review Article
Acute Peritonitis Generalized by Typhoid Perforation at Kankan Regional Hospital
Naby CS1*, Mampan KA2, Djoulde DA2, Togba SL3, Mohamed C1, Oumar S1, Mariame C4, Adama K5, Makhissa BA6, Lamine SM7,
Elisa T7, Tady K7, Aboubacar T3 and Taran DA3
1Department of visceral surgery, Hospital of the Sino-Guinean Friendship of Kipe, Faculty of Health Sciences and Technology, Gamal
Abdel Nasser University of Conakry, Conakry, Guinea
2Department of visceral surgery, Donka National Hospital, Faculty of Health Sciences and Technology, Gamal Abdel Nasser University of
Conakry, Conakry, Guinea
3Department of General Surgery, Ignace Denn National Hospital, Faculty of Health Sciences and Technology, Gamal Abdel Nasser Univer-
sity of Conakry, Conakry, Guinea
4Department of Anesthesia and Resuscitation, Faculty of Health Sciences and Technology, Gamal Abdel Nasser University of Conakry,
Conakry, Guinea
5Medical Imaging Department, Sino-Guinean Friendship Hospital of Kipe, Faculty of Health Sciences and Technology, Gamal Abdel Nasser
University of Conakry, Conakry, Guinea
6Department, of Emergency, Friendship Hospital Sino- Guinean of Kipe, Faculty of Health Sciences and Technology, Gamal Abdel Nasser
University of Conakry, Emergency Conakry, Guinea
7Department of Neurosurgery, Hospital of the Sino-Guinean Friendship of Kipe, Faculty of Health Sciences and Technology, Gamal Abdel
Nasser University of Conakry, Conakry, Guinea
*Corresponding author:
Soriba Naby Camara,
Department of visceral surgery,
Hospital of the Sino-Guinean Friendship of Kipe,
Faculty of Health Sciences and Technology,
Gamal Abdel Nasser University of Conakry,
Conakry, Guinea, E-mail: cnabysoriba@yahoo.com
Received: 11 Dec 2020
Accepted: 14 Dec 2020
Published: 05 Jan 2021
Copyright:
©2021 Naby CS. This is an open access article distributed under
the terms of the Creative Commons Attribution License, which
permits unrestricted use, distribution, and build upon your work
non-commercially.
Citation:
Naby CS
.
Acute Peritonitis Generalized by Typhoid Perforation
at Kankan Regional Hospital
. Japanese Journal of Gstroenter-
ology and Hepatology. 2021; V5(8): 1-5.
Keywords:
Acute peritonitis; Frequency; Clinical aspects; Therapy
1. Abstract
1.1. Aim: The aim of this study is to make our contribution to the
study of acute generalized peritonitis of typhus origin at the Kankan
Regional Hospital.
Typhoid perforation is dened as the opening of a hollow viscus in
the abdominal cavity due to salmonella.
1.2. Methodology: We carried out a 6-month prospective study
from June 1, 2019 to November 30, 2019 inclusive.
Were included in our study, all the patients operated on for peritonitis
by typhoid perforation and hospitalized in the department and in
whom the diagnosis of typhus perforation was made intraoperatively
and conrmed by the positivity of Widal and Félix in the department
during the study period. Any patient operated on for non-typhus
peritonitis was not included in the study. All patients diagnosed with
typhoid perforation but who died before surgery.
Results during our study period we had 423 patients of whom 8 per-
cent developed peritonitis from typhoid perforation. The study in-
volved 21 men and 12 women, for a sex ratio of 1.75, which showed
a clear predominance of the affection of men.
The history of gastroenteritis was noted in 45.45 percent of our pa-
tients, typhoid fever in 36.36 percent, malaria in 18.18 percent, ar-
terial hypertension in 12.12 percent and parasitosis in 9.09 percent.
However, perforations were single in 19 patients, double in 9 patients
and multiple in 5 patients. The treatment was medico-surgical, the
operative consequences were simple in 33 percent and complicat-
ed in 67 percent. Unfortunately, we had recorded 5 cases of death
against 28 cases of cure.
1.3. Conclusion: Acute generalized peritonitis represents frequent
1

tropical pathologies, the management is medico-surgical (Table 1).
2. Introduction
Peritonitis is dened as the inammatory response of all or part of
the peritoneum to an attack, the origin of which is most often infec-
tious (Monteiro et al. 2007) [1].
Typhoid perforation is dened as the opening of a hollow viscus in
the abdominal cavity due to salmonella [2]. Typhoid fever is a serious
multisystem infection caused by Salmonella typhi and sometimes by
Salmonella paratyphi [3]. It is usually transmitted by the faecal-oral
route and is often endemic [4]. An estimated 22 million people are
infected worldwide each year and 200,000 deaths [5]. The natural
course of Salmonella typhi infection can lead to ulceration and per-
foration occurs in the terminal ileum as a result of Peyer's patches
necrosis 2-3 weeks after the onset of the disease which ends to peri-
tonitis [6, 7] (Figure 1).
Typhoid perforation of the hail remains the digestive complication
of typhoid fever with signicant morbidity and mortality [8].
In most parts of the world, the perforation rate ranges from 0.6% to
4.9% of enteric fever cases. But in West Africa, higher rates of 10 to
33% have been observed [5].
In urban Africa, ileal perforations are often the leading cause of peri-
tonitis, with a mortality rate of up to 20% [9]. The mortality reported
in developing countries is linked to a variety of factors, including sep-
sis (diffuse peritonitis), late treatment, malnutrition in many patients,
age (many patients are young children) inadequate antibiotic therapy
and the scarcity or the total absence of therapeutic resources [4].
In the USA in 1996 GROSFELD et al. [10], reported a frequency of
58.65% of typhoid perforation peritonitis (Table 2).
In Turkey in 2007 Gedik E et al. Reported that the incidence of en-
teric perforation of typhoid origin was between 0.5 and 78.6% [11].
In Togo in 2016 Kassegne I et al. Reported a frequency of 67.9% of
acute generalized peritonitis by Typhic perforation [12]. In Burkina
Faso in 2016 Ouedraogo S et al. reported that 42.5% of the etiolo-
gies of peritonitis were related to typhoid fever [9]. In Mali in 2013,
Togola B et al. Reported that 29.0% of peritonitis was of typhoid
origin [13].
In Guinea.
DIALLO T.M in 2013 at the regional hospital of Labe, Yattara A
in 2014 at the prefectural hospital of Dubreka reported a respective
frequency of 2.64% and 1.49% [14, 15].
While the position of the problem is well known in large urban hos-
pitals, it is less so in secondary hospitals in Africa where the problem
seems more worrying [9].
3. Methodology
It was a prospective, descriptive study lasting 6 months from June 1
to November 31, 2019 (Figure 2,3,4).
Figure 1: Frequency of typhus peritonitis compared to other etiologies of peritonitis.
Figures 2,3,4: show ileal typhoic perforals
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2021, V5(8): 1-2

Table 1: Distribution of patients according to the reasons for consultation.
Motifs de consultation Frequence %
Abdominal pain 33 100
Fever 33 100
Anorexia 30 90,90
Physical asthenia 28 84,84
Vomiting / Nausea 26 78,78
Stopping of materials and gases 25 75,75
Voiding burn 5 15,15
Diarrhea 3 9,09
Table 2: Distribution of patients according to medical history.
Medical history Frequency %
Gastroenteritis 15 45,45
Typhoid fever 12 36,36
Malaria 6 18,18
HTA 4 12,12
Parasitosis 3 9,09
We targeted all patients received and operated on in the surgical
wards of Kankan Regional Hospital for acute peritonitis during our
study period. The study actually looked at patients operated on for
acute typhoid perforation peritonitis during our study period. Were
included in our study, all the patients operated on for peritonitis by
typhoid perforation and hospitalized in the department and in whom
the diagnosis of typhus perforation was made intraoperatively and
conrmed by the positivity of Widal and Felix in the department
during the study period (Table 3).
• Not included in this study
• Any patient not operated on and hospitalized in the de-
partment;
• Any patient operated elsewhere and received in the wards
for another complication
• Any patient operated on for non-typhus peritonitis.
• All patients diagnosed with typhoid perforation but who
died before surgery.
• We conducted an exhaustive recruitment of all patients
who met our inclusion criteria.
• For the collection of our data the following steps have been
respected
• Our study variables were quantitative and qualitative
Table 3: Distribution of patients according to physical signs.
physical Signs Frequency %
Umbilical cry positive 33 100
Defense or contracture 33 100
Douglas Cree 33 100
Abdominal distension 23 69,69
Tympanism / Meteorism 15 45,45
Dullness 13 39,39
4. Results
• The main postoperative complications were among others
• Wall suppurations in 36.36 percent,
• Intra-abdominal abscess in 18.18 percent
• Stercoral stulas in 22.72 percent,
• Sepsis in 13.63 percent
• Eventration in 9.09 percent
• Average length of hospitalization was 20.82 days with the
extremes of 7 and 72 days
• We had recorded 85 percent recovery versus 15 percent
death.
5. Discussions
During our study period, we recorded 33 cases of PAG / PT of the
small bowel out of 423 patients admitted and operated, i.e. a frequen-
cy of 7.80%.
This result is higher than that of Diallo T M in 2017 at the regional
hospital of Labe [14] who reported a frequency of 2.64%, but lower
than those of Togola B et al. [13] in 2019 in Mali which reported a
frequency of 29%.
This high frequency of PAG / PT could be explained on the one
hand, the lack of health education, promiscuity, the low socio-eco-
nomic level favoring the spread of typhoid fever and on the other
hand self-medication, the delay in the consultation and use of tradi-
tional medicines are non-compliance with hygienic rules and the use
of traditional medicines.
This result is comparable to those of Verma H et al. [17] in 2015 in
India who reported that 85% of patients were of rural origin and
lower than that of Diallo TM [14] in 2017 at Labe regional hospital
which reported a predominance of the urban area with a frequency
of 39.47%.
This result could be explained by the lack of health education, im-
proved health centers and poverty.
The clinical picture of the patients was dominated by abdominal pain
and fever in all patients, gas and fecal arrest in 75.75%, physical as-
thenia 84.84% and vomiting / nausea 78.78%.
Our result conrms those of Ibrahim M et al. [3] in 2013 in Ni-
geria who reported that 97.9% of patients presented classic clinical
signs of typhoid perforation peritonitis and superimposed on those
of Ugochukwu AI et al [23] in 2013 in Nigeria who reported that
patients presented of the following signs on admission: abdominal
pain (90.7%), abdominal distension (75.6%), nausea and vomiting
(70.9%), constipation (54.7%) and fever (50.1 %).
Time to admission or perforation: The average time to admission for
our patients was 10.5 ± days with extremes of 3 and 19 days.
This result is different from that of Coulibaly C A T in 2011 in Mali
in his doctoral thesis which reported that the perforation takes place
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2021, V5(8): 1-3

in the second septenary (period between 7 and 14 days).
This difference could be explained by the high dose of antibiotics
and traditional drugs.
In our study, gastroenteritis was the most common antecedent,
45.45% followed by typhoid fever, or 36.36%.
General signs: In our study, 93.93% of patients presented with fever,
followed by physical asthenia 84.84% and weight loss or 42.42%.
All the patients presented the signs of peritoneal irritation namely:
abdominal contracture, umbilical and Douglass cries, abdominal dis-
tension was present in 69.69%.
This result can be applied to that of Sanogo ZZ et al [6]. in 2013 in
Mali, who reported that on physical examination there was general-
ized abdominal defense in 81.6%, abdominal contracture in 87.5%,
and umbilical cry in 88.3% of patients.
Additional examinations: In our study, Félix and Widal serology was
positive in all patients.
This result corroborates that of Kouame BD et al [8] in 2001 in Ivory
Coast who reported that the serodiagnosis of WIDAL and FELIX
was positive in all patients and those of Togo A et al [24] in 2009 in
Mali who reported that Widal's sensitivity was 82%.
Note that the sensitivity and specicity of this test are respectively
close to 52% and 88%. It would be enough alone to make the diagno-
sis when blood cultures and stool cultures are not available (Table 4).
Table 4: Distribution of patients according to the number of perforations
Number of perforation Number of cases Percentage
Unic Perforation 19 27,27
Doubles 9 57,58
Multiples Perforations 5 15,15
Total 33 100
Pre and postoperatively, all of our patients received antibiotic ther-
apy, analgesics and intravenous rehydration followed by iso-rhesus
group blood transfusion, i.e., 63.63%.
Antibiotic regimen: In our study, the most used antibiotic regimen
was the bi therapy compound Ceftriaxone 1g and infusable metro or
ceftriaxone 1g and levooxacin 500mg, i.e. 66.66% followed by triple
therapy consisting of ceftriaxone 1g + infusable metro + gentamycin
80mg or 27.27%.
This result is comparable to those Kambire J.L et al. [19] in 2017 in
Burkina Faso who reported that bi-antibiotic therapy based on third
generation cephalosporins and metronidazole Injectable was used in
all patients (i.e. 100%), and those of Sharma AK et al [6] in 2013 in
India who reported that the 3rd generation cephalosporin + met-
ronidazole + uoroquinolone triple therapy was administered to all
patients for 7 days.
This result could be explained by the high sensitivity of germs to
different antibiotics
Look rst:
In our study, midline supra and subumbilical laparotomy was per-
formed in all of our patients.
The surgical techniques depended on the number of perforations
and their location.
• Simple excision-suture 72.72%
• End-to-end intestinal resection and anastomosis 27.27%
• abundant washing with 0.9% 100% saline serum
• drainage in sloping areas was observed 100%.
This result corroborates those of Kassegne I et al. [04] in 2016 in
Togo who reported that the surgical techniques were: Intestinal ex-
cision-suture, intestinal resection and anastomosis and ileostomy
resection with a respective frequency of 54.5%, 32.8% and 12.7%.
Operative follow-up: In our study, the operative follow-up was fa-
vorable in 33.33% and was accompanied by complications in 67.67%
of cases.
This result is lower than those of Ouedraogo S et al. [9] in 2017 in
Burkina Fasso who reported in their study that 72.2% of patients
presented postoperative complications.
The most frequent complications were parietal suppuration in
36.36%, stercoral stula in 22.72%, intra-abdominal abscess 18.18%
sepsis 13.63%, eventration / evisceration in 9.09% of patients.
This result is close to those of Conventi R et al. [18] in 2018 in
Uganda who reported that wall suppuration was the most common
complication with a frequency of 40.42%.
During peritonitis there is an overgrowth of bacteria making the sur-
gery septic which increases the risk of complications. We recorded a
total of 5 deaths or 15.15%.
This result corroborates those of Sissoko F et al [22] in 2003 in Mali
who reported a mortality rate of 16% and is higher than those of
Conventi R et al [18] in 2018 in Uganda who reported a mortality
rate. by 5.56%.
This high rate of death could be explained by the occurrence of
complications namely: sepsis, septic shock, multiple visceral failure
plus other complications. But also the lack of preoperative resusci-
tation.
The average length of stay was 20.82 ± days with extremes of 7 and
72 days.
Our result is comparable to those of Sanogo ZZ et al [6] in 2013
in Mali who reported an average hospital stay of 20.6 days with ex-
tremes of 10 and 35 days and higher than that of Diallo TM [14]
in 2017 at the regional hospital of Labe which reported an average
hospital stay of 14.5 days with extremes of 1 and 30 days.
This long stay of patients could be explained by the occurrence of
postoperative complications (Table 5).
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2021, V5(8): 1-4

Table 5: Distribution of patients according to the antibiotic use pattern.
Antibiotic Frequency %
Ceftriaxone 2 6,06
Ceftriaxone + Metronidazol perf 18 66,66
Ceftriaxone 1g et lévooxacine 500mg 4 12,12
Ceftri 1g + Metro perf + Genta 80mg 9 27,27
6. Conclusion
It emerged from this study that acute generalized peritonitis by ty-
phoid perforation is a serious and frequent surgical pathology at
Kankan Regional Hospital.
It mainly affects young, predominantly male subjects and immediate-
ly produces a frank acute peritonitis syndrome in an asthenic context.
The diagnosis is clinical and paraclinical, the management is medical
(resuscitation measures and antibiotic therapy) and surgical (excision
+ suture and resection + anastomosis).
Resuscitation measures and the use of antibiotics improved the prog-
nosis of typhoid perforations.
However, morbidity and mortality are still signicant.
The reinforcement of hygieno-dietary measures and early treatment
could improve the patient's vital prognosis.
References
1. Kassegne I, Kanassoua KK, Sewa EV, Tchangai b, Sambiani DM, Ay-
ite AE et al. Management of generalized peritonitis in Kara teaching
hospital en octobre 2013.
2. Ibrahim KM. Etude des perforations ileales d’origine typhique dans
le service de chirurgie de l’hopital Somine Dolo De Mopti. These de
medecine: universite de bamako en 2008 2009.
3. Ibrahim M, Getso KI, Y ashuwa AH, Mohammad AM, Anyanwu LJ et
al. Single-layer closure of typhoid enteric perforation: Our experience.
Afr J Paediatr Surg. 2013; 10: 167-71. doi: 10.4103/0189-6725.1 15046.
4. Caronna R, Boukari A K, Zaongo D, Hessou T, Gayito R C, Ahonon-
ga C et al. Comparative analysis of primary repair vs resection and
anastomosis, with laparostomy, in management of typhoid intestinal
perforation: results of a rural hospital in northwestern Benin Pub-
lished online. 2013; 13-102.
5. Ukwenya AY, Ahmed A, Garba ES. Progres dans la gestion de la per-
foration de la typhoide - Ann Afr Med en 2 novembre 2011; 1596-
3519. 87040.
6. Sanogo ZZ, Sanogo B, Koita A, Traore D, Camara M, Traore S et al.
Typhoid ileal perforations: clinical and therapeutic aspects in tropical
Land en. 2013; BP 333.
7. Sharma AK, Sharma RK, Sharma SK, Sharma A, Soni D. Typhoid In-
testinal Perforation: 24 Perforations in One Patient. 2013; 3: S41-S43.
8. Kouame BD, Ouattara O, Dick RK, Gouli JC, Roux C. Aspects diag-
nostiques, thérapeutiques et pronostiques des perforations typhiques
du grêle de l’enfant à Abidjan, Cote d’Ivoire en. 2001; 94: 379-82.
9. Ouedraogo S, Ouangre E, Zida M. Epidemiological, clinical, and ther-
apeutic features of typhoid intestinal perforation in a rural environ-
ment of Burkina Faso. en 2017; 27: 67-70.
10. Traore ML. Diagnostic des salmonella dans les peritonites aigues par
perforation ileale dans la region de Sikasso These de Medecine: uuni-
versite de bamako en 2009.
11. Gedik E, Girgin S, Taçyildiz IH, Akgun Y. Risk factors affecting mor-
bidity in typhoid enteric perforation. Langenbecks Arch Surg. 2008;
393: 973-7.
12. Kassegne I, Sewa EV, Kanassoua KK, Alassani F, Adabra K, Amavi
AK et al. Diagnostic, therapeutic, and prognostic aspects of typhoid
intestinal perforations in Dapaong, Togo. Med Sante Trop. 2016; 26:
71-4. doi: 10.1684/mst.2016.0544.
13. Togola B, Coulibaly B, Traore D, Traore A, Koita A, Keita K et al. Peri-
tonitis by typhoid ileal perforation: evolutionary aspects in the Teaching
Hospital of Bamako and Kati in Mali. Mali Med. 2013; 28: 1-5.
14. Diallo M. Peritonite aigue generalisee par perforation typhique: aspects
epidemiologique clinique et therapeutique a l’hopital regional de Labe
These de medecine: UGANC en 2013.
15. Yattara A. Peritonite aigue generalisee par perforation typhique du
grele: aspects epidemiologique, clinique et therapeutique a l’hopital
prefectoral de dubreka. These de doctorat en medecine: UGANC N°:
034/2014.
16. Cheick ATC. Etude des peritonites par perforation typhique du grele
dans le service de chirurgie pediatrique du CHU GABRIEL Toure.
These de doctorat en medicine: Universite de bamako En 2011.
17. Verma H, Pandey S, Sheoran KD, Marwah S. Surgical Audit of Patients
with Ileal Perforations Requiring Ileostomy in a Tertiary Care Hospital
in India. Published online 2015. doi: 10.1 155/2015/351548.
18. Conventi R, Pellis G, Arzu G, Nsubuga JB, Gelmini R. Intestinal perfo-
ration due to typhoid fever in Karamoja (Uganda Ann Ital Chir. 2018;
89: 138-148
19. Kambire J L, Ouedraogo S, Ouedraogo S, Ouangre E, Traore SS. Re-
sults after Surgical Management of Ileal Perforation Due to Typhoid
Fever, About 29 Cases in Ouahigouya (Burkina Faso). Pathol. Exot.
2017; 110: 297-9.
20. Jamai, Kouider N, Faiza A, Fouzia H. La evre typhoïde. These de
doctorat en medecine: universite d’Algerie en 2010.
21. Kouassi JC, Diane B, Lebeau R, Yenon K, Kouakou B. Traitement
chirurgical des perforations de l’intestin grele d’origine typhique au chu
de Bouake. Revu. Int. Sc. Med. 2006; 8: 10-13.
22. Sissoko f, ongoiba n, berete s, diarra s, Coulibaly y, doumbia Sidibe s
et al. Traore a.kr dit diop, koumare a.k les peritonites par perforation
iléale en chirurgie « b »de l’hopital du point-« g » these de doctorat en
médecine en 2003 a l’universitede Bamako.
23. Ugochukwu ai, amu oc, nzegwu ma; ileal perforation due to typhoid fe-
ver - review of operative management and outcome in an urban centre
in nigeria; int j surg. 2013; 1: 218-22. doi: 10.1016/j.ijsu.2013.01.014.
epub 2013 feb 9.
24. Coulibaly AY, Kante I, Traore A, diango DM, Keita BT. Dembele I et
al. typhoide perforations at the teaching hospital Gabriel Toure of Ba-
mako (mali); journal africain d’hépato-gastroentérologie 2009; 3.
25. CT Kumel kumelundu kasongo, msc D.E.A. evaluation des souches
de salmonella typhi impliquées dans les péritonites et leur sensibilité
aux antibiotiques. etude menée dans quelques hôpitaux de Kinshasa
en 2013.
5
2021, V5(8): 1-5