Typhoid fever is regarded as the most common cause. Role of Ileostomy in Enteric Perforation. Original Article. Shashikant Shah 1, Jenit P Gandhi 2

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1 DOI: /SUR/2015/04 Role of Ileostomy in Enteric Perforation Original Article Shashikant Shah 1, Jenit P Gandhi 2 1 Professor, Department of Surgery, SBKSMI & RC, Vadodara, Gujarat, India, 2 Resident, Department of Surgery, SBKSMI & RC, Vadodara, Gujarat, India Abstract Introduction: Enteric perforations have been seen as a common problem in tropical countries. Over a period the trend of enteric perforations has changed, its treatment, disease progression and prognosis. Methods: The studies of 25 cases of ileal perforations treated and underwent an ileostomy as a treatment modality between the periods of May 2010-August 2012 were included. Traumatic ileal perforations and ileal perforation without an ileostomy were excluded from the study. Results: In a study conducted commonest cause was Enteric fever in nonspecifi c ileal perforations. Perforation commonly occurred in second and third with 48% of patients belongs to the age group between 11 and 30. The mean age of the patients in the study was 33 years. Male preponderance with male to female ratio 5:1 was observed. Pneumoperitoneum in chest and erect abdominal X-ray was seen in 84% of the patients. Time between onset of pain and surgical intervention (Lag period) was between 10 and 96 h with the mean of h. Single ileal perforations were seen in 84% of the cases with 72% being located within 30 cm from ileocecal junction (ICJ). Majority were located within 60 cm from ICJ (96%). Conclusions: A non-specifi c enteric perforation (60%) was the most common cause of ileal perforation. Ileostomy as a treatment modality carried a mortality rate of 4%. Ileostomy closure an overall complication rate of 24%. Wound infection, small bowel obstruction and enterocutaneous fi stula were commonly seen complications. 12% cases had small bowel obstruction managed conservatively. Keywords: Crisis Intervention, Ileostomy, Pneumoperitoneum INTRODUCTION Typhoid fever is regarded as the most common cause of ileal perforation in India. Typhoid fever caused by Salmonella enterica serovars typhi S. enterica is a gram-negative intracellular pathogenic bacterium, which infects human. S. enterica includes 2500 serovars of which most of them are pathogenic to humans. However, some prototypes are highly specific like S. typhi or Salmonella paratyphi. It can also spread through feco-oral route and have the incubation period of days, but may vary from 5 days to days depending upon the size of the inoculum and the immune status of the host. Diagnosis Access this article online Month of Submission : Month of Peer Review : Month of Acceptance : Month of Publishing : of the disease has to be confirmed by the presence of pathogen either S. typhi or S. paratyphi in the patient, which requires isolation of the bacteria from the blood, stool or bone marrow. The sensitivity of the test decreases with the increased duration of fever. Another method commonly used in today s scenario is Widal test, that detects antibodies against Salmonella O (Somatic) and H (flagellar) antigens in the serum, which usually appears in the 2nd week after the disease onset thereby proving the existence of the species in the body. Major public health challenge is the typhoid fever caused by S. typhi or S. paratyphi it has a global incidence of 21 million cases and responsible for 4% death worldwide. 1 The West African region has one of the highest perforation rates in the world (15-33%), and the reason for the same remains a speculation. Despite decades of improvement in patient care, the morbidity and mortality of typhoid perforation remain high, and this is related to variable factors. 2-4 The incidence of typhoid perforation has been reported to be 27.3/1000 person-year in children less than 5 years of age. Serious complications are an associated Corresponding Author: Dr. Jenit P Gandhi, Department of Surgery, SBKSMI & RC, Vadodara, Gujarat, India. jenitgandhi@yahoo.com 10 IJSS Journal of Surgery January-February 2015 Volume 1 Issue 1

2 feature in about 10% of cases requiring hospitalization. 5 After initial resuscitation with intravenous fluids and correction of electrolyte, emergency laparotomy is performed to manage the disease. However, diagnosis of the Typhoid perforation is seldom confirmed in the majority of these cases of the enteric perforation. Only a convectional diagnosis is based on the circumstantial evidence of terminal ileal, anti-mesenteric perforation in an adult running fever for more than 2 weeks. Widal test, although a routinely done test, is non-specific, and it is difficult to interpret, especially in endemic zones. Majority of the patients present with sudden onset of abdominal pain. Most of the patients come from the rural areas and reach the average delay of 2-3 days after onset of acute illness, thereby leading to high mortality associated with these cases. A high index of suspicion is required to diagnose hollow viscous perforation early as significant mortality and morbidity results from diagnostic delay. Ileostomy is an operative procedure in which a loop of ileum is exteriorized to the abdominal wall in the form of exteriorization of the diseased segment without resection or exteriorization of the perforation site with or without suturing. It is done as a part of surgical procedure which involves gross peritoneal contamination, edematous bowel loop, multiple perforations of small bowel, pregangrenous changes of small bowel or hypoproteinemia, because primary suturing without exteriorization has a high risk of leakage and related morbidity and mortality. A majority of ileostomies are performed without serious complications. With the understanding of the stoma site marking, principles of stoma creation and role of dietary modifications many problems of stoma care could be prevented. Hence, creation of the stoma does not add to the morbidity. It helps in early oral intake of patients. METHODS This study was conducted on the basis of the patients admitted with acute abdomen to the emergency or OPD patients from May 2010 to August 2012 found having ileal perforation and underwent an ileostomy were included in this study. Patients having other disease were excluded from the study. In this study, 25 cases of the enteric perforation and adhering to a common protocol in their investigation and management plan so as to achieve the aims and objectives are outlined. All patients were resuscitated preoperatively with intravenous fluids and antibiotics. Patients unfit for surgery were initially treated with flank drains under local anesthesia as a temporary measure prior to definitive laparotomy. Most cases received cefaparazone + sulbactam 1.5 g, aminoglycosides and metronidazole. All patients underwent laparotomy under general anaesthesia; a midline incision was employed. The amount and type of peritoneal contamination, number, site and size of perforation were noted. Since all the cases in this study had gross peritoneal contamination, the perforated ileal loop was isolated, biopsy taken from the perforation wall and loop was brought out as an ileostomy. Peritoneal wash was given, and abdomen was closed. Antibiotics were routinely given, for 7-10 days unless the diagnosis was typhoid in which case antibiotics were continued up to 14 days. A diagnosis of typhoid was made only if Widal test was positive. When the etiology of non-traumatic perforations was found, it was termed non-specific. Post-operative complications were noted. The factors influencing mortality and morbidity and outcome were assessed. Inclusion criteria included Ileal perforation and distal ileal perforation of any etiology. Although, patients with duodenal perforation, jejunal perforation and traumatic ileal perforation were excluded from the study. RESULTS In a study conducted most common cause was enteric fever in nonspecific ileal perforations. Perforation commonly occurred in second and third with 48% of patients belongs to the age group between 11 and 30. The mean age of the patients in the study was 33 years. Male preponderance with male to female ratio 5:1 was observed. Pneumoperitoneum in chest and erect abdominal X-ray was seen in 84% of the patients. Time between onset of pain and surgical intervention (Lag period) was between 10 and 96 h with the mean of h. Single ileal perforations were seen in 84% of the cases with 72% being located within 30 cm from ileocecal junction (ICJ). Majority were located within 60 cm from ICJ (96%). DISCUSSION The most common cause of ileal perforation in the series was non-specific ileal perforation accounting for 60% of cases. Typhoid fever was the second common cause of ileal perforation in 36% of cases. Non-specific perforations accounted for 52.94%, in study series by Nadkarni (1981). Whereas typhoid perforation was second common cause of ileal perforation accounting for 23.52% by Nadkarni. 6 Table 1 shows the incidence of typhoid perforations in different countries reported by different authors. When the etiology of perforation was not identified, it was termed as non-specific perforation. It was the leading cause of ileal perforation in the study. Seven patients with non-specific perforation had fever prior to the onset of abdominal pain. A diagnosis of non-specific perforation IJSS Journal of Surgery January-February 2015 Volume 1 Issue 1 11

3 was made when Widal test, stool examination was not suggestive of typhoid. These cases could be undiagnosed cases of typhoid. However according to Capoor et al. (2008), enteric fever organism is not the predominant causative agent of perforations. 7 Typhoid fever was accounted for nine patients (36%) of the cases. It was the second most common cause of ileal perforation in the study. It was diagnosed on the basis of Widal positivity. Tuberculosis accounted for 4% of cases of ileal perforations in this study. 4.9% of intestinal TB undergoes perforations. 8 If treated with higher antibiotics, early start of enteral feeding and anti-tubercular drugs carries a good prognosis. In this study, there was a solitary perforation. In 90% of cases, the perforation is solitary. 9 Multiple tubercular perforations carry a poor prognosis. In our study, patient had solitary perforation. In our study, the mean age was (range from 6 to 75 years). In a study conducted by Kayabali et al. (1990) mean age was Another study by Atamanalp et al. (2007) mean age was found to be 36.3 years. Table 2 below describes the mean age of patients that participated in various studies. Typhoid perforations in the case of study by Eggleston et al. reported perforations occurring in second and third. In the case of our study 80% belonged to the second and third (Table 2). Patient suffering from TB was in the eighth. There was male predisposition with male: Female ratio being 5:1. With typhoid perforations accounting for 2:1. Young males are the most common sufferers. Table 3 shows the mean age of incidence and sex of the patients in the different studies. Table 1: Incidence of typhoid perforations as reported by various authors Author Year Country Number (%) Archampong 1976 Ghama 20.5 Arigbabu 1980 Nigeria 78.6 Bhalerao 1981 India Santillama 1991 Peru 7.8 Wani et al India 62 Table 2: Mean age of patients in different studies Kayabali et al. Atamanalp et al. Our study Mean age The increasing occurrence of typhoid intestinal perforations in this age group in our setting can be due to the fact that majority of them were youths and they are comparatively more adventurous as well as mobile and could have higher chances of eating unhygienic food outdoors. Alongside, a higher risk of fecal contamination because of their visits to the toilets at public places. 11 Majority of the patients had signs and symptoms of peritonitis. The most common symptoms were abdominal pain, vomiting, and fever. All the patients had the chief complaint of abdominal pain. 80% of patients had vomiting, and 72% had fever. Constipation was present in 68% of cases. Whereas, just 8% cases came with a complaint of diarrhea. It was tough to diagnose the case associated with diarrhea with dilemma of whether to operate or not on clinical findings. But with the help of laboratory findings and signs of toxaemia patients were operated and got the treatment. Abdominal guarding was present in 96% of cases, abdominal distension in 80% of cases (Table 3). Five patients present with shock on admission and the other nine patients were in different degrees of dehydration. Examination showed the signs of acute abdomen and toxaemia. Table 4 shows the different signs and symptoms that were present in various studies. Majority of the perforations was located within 60 cm from the ICJ. In 17 patients (68%) the perforations were located within 30 cm from ICJ. A study by Badejo and Arigbabu (1980) reported location of perforation between 20 and 40 cm from ICJ. 12 Wani et al. (2006) also reported operative findings are typical with most perforations being located on antimesenteric border of the terminal 60 cm part of the ileum. Table 5 denotes and compares the site of perforation in various studies. Midline laparotomy with ileostomy was performed in all the patients. The ileostomy was supported by a K 90 drain to avoid retraction (Table 6). Waxner et al. (1993) also suggest the use of supportive rods. 13 In this current study, majority of perforation occurred in the 1 st week of the disease. Patients who perforate in the first 2 weeks have the better prognosis. In developing countries, cases are reported as early as the 1 st week of the disease. 11 Chest X-ray was useful and Table 3: Comparison of incidence and sex with other studies Incidence Typhoid ileal perforations sex ratio Adesunkanmi and Ajao Eggleston et al. (1979) Chalya et al..(2012) Our study 4:1 3.5:1 2.6:1 2:1 12 IJSS Journal of Surgery January-February 2015 Volume 1 Issue 1

4 reliable investigation to detect the perforation. Free gas under the diaphragm was seen in 84% of the patients. Pneumoperitoneum had been reported in 52-82% in the studies by Archampong, Vaidyanathan, Hadley, Tacylidiz, Chalya and Chatterjee. 11,14-17,18 Widal was positive in 36% of cases. Table 7 shows the percentage of cases in different studies where Widal was positive. S. typhi was grown in 1 patient with typhoid ileal perforation in whom blood culture was done. It was not a routine investigation and not seen for every patient. Routine unit protocol was performed. The culture report was sensitive to amikacin, ceftriaxone, sulbactam, piperacillin. Hadley had reported positive culture in 22.2% and Santillana in 48% in 48% of the patients. 16,17 Prior antibiotic therapy was responsible for the low isolation in the study. 16 Typhoid fever is caused by Gram-negative bacilli S. typhi. The organism passes through the payer s patches without causing inflammation. Multiplication occurs in the reticuloendothelial system for days. Seeding occurs in the blood stream corresponding to the clinical onset. During the 2nd week of illness, bacteria reach the gut and localize in payer s patches. Ulceration and medentericadenitis occur. Necrotic areas appear in lymphoid tissue. This might lead to perforation of payer s patches. Tuberculosis was diagnosed on the Table 4: Comparison of signs and symptoms Criteria Eggleston et al. (%) Chalya et al. (%) Our study (%) Fever Abdominal pain Vomiting Diarrhoea Constipation Abdominal distension Table 5: Location of the perforation Badejo and Wani et al. Our study Arigbabu Site of perforation cm from ICJ 60 cm from ICJ Within 60 cm from ICJ 68% within 30 cm from ICJ ICJ: Ileocecal junction Table 6: The use of supportive rods to prevent ileostomy retraction Waxner et al. Our study Ileostomy support Supportive rods K 90 drain as supportive rods Table 7: Comparison of Widal positivity with another study Kaul Santillana Our study Widal positivity (%) basis of histopathological report. In our case series, the patient did not have Widal positivity. Patient with tubercular perforation was in his eighth and had the previous history of tuberculous infection and had taken full course anti-tubercular drug. In this study, all patients had moderate to massive peritoneal contaminations. Seven patients (28%) out of 25 had moderate contamination. Rest of the 72% had massive contamination. Hence to reduce the mortality in these patients ileostomy as a treatment modality was chosen. The no suture line in the procedure seems to be a better option in adverse patient conditions. 19 Primary closure is only done when patient presents early, and the bowel looks healthy. Sepsis and bowel edema makes suturing hazardous so primary closure should be avoided in patients presenting late. 20 A loop ileostomy is considered easier to manage and is not associated with greater rate of complications. 21 In our study, the majority of the patients were treated with cefaparazone + sulbactam combination along with metronidazole. In a study carried out by Chatterjee et al. (2009) broad spectrum antibiotics in different combinations with metronidazole were administered postoperatively. 18 A simple drain was kept for average 48 h with the ileostomy site. In this case series all patient had undergone ileostomy. In the majority of patients (88%) of the patients perforations were solitary, and 32% patient had impending perforations. Loop ileostomy proved to be beneficial in patients with impending perforations. The majority of the patients (84.6%) had single perforation and ileum was the most common part of the small intestine affected occurring in 86.2% of cases in the study by Chalya et al. (2012). 11 Karmacharya and Sharma (2006) in this study also revealed that 65.6% had solitary perforation involving terminal ileum. 2 Mock et al. revealed in 78.5% involving terminal 30 cm of ICJ. 22 Table 8 compares the number and site of perforations in different studies (Table 8). The most frequent complication was wound infection in our study. According to study by Abantanga common complications was wound infection. 23 Similar study was carried out by Ahmed et al. (2006) reported wound infections as most common complications. 24 Most dreaded complication was fecal fistula that was, fortunately not found in our study. Mortality rate in case of nonspecific perforations was 4%. There was no mortality in Table 8: Comparison of number and site of perforation with other studies Karmacharya Mock Chalya Our and Sharma et al. et al. study Solitary perforation (%) Involvement of terminal ileum Present Present Present Present IJSS Journal of Surgery January-February 2015 Volume 1 Issue 1 13

5 case of typhoid or tubercular perforations in our study (Table 9). Non-specific perforation therefore carries a poor prognosis in comparison to other causes of ileal perforation. Typhoid fever is a major cause of mortality in developing countries, with a case-fatality rate of 12-32%, whereas in developed countries this rate has been successfully reduced to <2%. 25 The procedure of choice was same in all patients irrespective of the etiology. Only those patients who underwent an ileostomy were considered for the case study. Three patients out of them developed wound infection and wound dehiscence. None of the patients developed fecal fistula. Lag period has an influence in the development of morbidity and mortality. There was no significant difference in morbidity and mortality in these cases. Lag period was however proportional to the degree of peritoneal contamination. Increased lag period resulted in the higher degree of peritoneal contamination. Table 10 compares the perforation operation lag period in different studies. Ileostomy closure was carried no mortality and low complication rate. Overall post ileostomy closure complication rate was 24%. In a study conducted by Thedioha et al. (2010) overall complication rate was 18%. 26 Post ileostomy closure complications were commonly seen in Typhoid perforations with 2 (22.22%) out of nine patients. Of which 1 (11.11%) suffered from small bowel obstruction. Patient with non-specific perforations had wound infection in 1 patient and small bowel obstruction in 2 patients. None of the patients had anastomotic leakage (Table 11). Only one patient who had tubercular perforation had late complication of entero-cutaneous fistula formation. Wound infection rate in our study was present in 2 (8%) patients following ileostomy closure. Mann et al. (1991) and Peacock (2012) had wound infection rate of %, respectively. 27,28 In this study, 12% patients of ileostomy closure had small bowel obstruction. Similar studies conducted earlier also reveal 12% going into small bowel obstruction. 26,27 All the patients who underwent small bowel obstruction were treated conservatively in this study. Similar studies conducted previously also had % patients being managed conservatively. 13,26-28 Table 9: Mortality rates in typhoid ileal perforation Author Year Mortality rate (%) Badejo Hadley Tacyilidiz (prospective) Kame et al Our study 4 CONCLUSION Non-specific perforations are the most common cause of ileal perforation followed by typhoid and tuberculosis. There was a male preponderance with the male to female ratio as 5:1. Perforation usually occurred in the 1 st week of illness. Chest X-ray is a useful diagnostic tool. Widal serology although done routinely is not the sole criteria for the diagnosis of the disease. Histopathology is useful in the diagnosis of tuberculosis. However not useful in the diagnosis of typhoid. Solitary ileal perforation was seen in the majority of the patients. Ileostomy in Enteric perforation proved to carry lesser morbidity and mortality rate. No mortality was seen in typhoid perforation. Increase in the lag period resulted in a higher degree of peritoneal contamination. The overall complication rate of ileostomy closure is 24%. Post ileostomy closure, Wound infection, Small bowel obstruction and enterocutaneous fistula (ECF) were commonly seen complications. Small bowel obstruction occurred in 12% of cases and was managed conservatively. Treatment of ECF required surgical intervention. With the advent of current antibiotic therapy, the rate of typhoid perforation has decreased. However, cases of perforation occurring as early as in the 1 st week have become more common. Ileostomy as a treatment modality carries lower mortality rate due to the early start of enteral feeding and nutritional built up higher rate of morbidity due to increased hospital stay. Exteriorization of the suture line is a superior method of treatment and significantly decreases the mortality. Treatment of choice for temporary fecal diversion is Temporary loop ileostomy, as most of its complications are managed non-operatively. Primary closure should be reserved for the patient who presents early without gross peritoneal contamination. Patient who presents late should be treated by an ileostomy. Refreshing the edges, double layer closure of the perforation and an ileostomy proximal to perforation in a relatively healthy looking Table 10: Perforation operation delay Perforation operation delay in hours Wani et al. N (%) Our study N (%) Within 24 h 23 (29) 6 (24) h 27 (34) 9 (36) h 11 (14) 8 (32) h 13 (17) 2 (8) h 2 (3) h 3 (4) Table 11: Comparison of post ileostomy wound infection with other studies Mann et al. Peacock Our study Wound infection (%) IJSS Journal of Surgery January-February 2015 Volume 1 Issue 1

6 bowel is the safe procedure in typhoid ileal perforation presenting late. This study concludes that an ileostomy surpasses other procedures in the treatment of ileal perforations. REFERENCES 1. Crump JA, Luby SP, Mintz ED. The global burden of typhoid fever. Bull World Health Organ 2004;82: Karmacharya B, Sharma VK. Results of typhoid perforation management: Our experience in Bir Hospital, Nepal. Kathmandu Univ Med J 2006;4: Adesunkanmi AR, Ajao OG. Prognostic factors in typhoid ileal perforation: Aprospective study in 50 patients. J R Coll Surg Edinb 1997;42: Ameh EA. Typhoid ileal perforation in children: A scourge in developing countries. Ann Trop Paediatr 1999;19: Sharma P, Taneja DK. Typhoid vaccine: A case for inclusion in national program. Indian J Public Health 2011;55: Nadkarni KM, Jahagirdar RR, Kagzi RS, Pinto AC, Bhalerao RA. Surgical obstructive jaundice. J Postgrad Med 1981;27: Nadkarni KM, Shetty SD, Kagzi RS, Pinto AC, Bhalerao RA. Small-bowel perforations. A study of 32 cases. Arch Surg 1981;116: Kayabali I, Gökçora IH, Kayabali M. A contemporary evaluation of enteric perforations in typhoid fever: Analysis of 257 cases. Int Surg 1990;75: Ihedioha U, Muhtaseb S, Kalmar K, Donnelly L, Muir V, Macdonald A. Closure of loop ileostomies. is early discharge safe and achievable? Scott Med J 2010;55: Atamanalp SS, Aydinli B, Ozturk G, Oren D, Basoglu M, Yildirgan MI. Typhoid intestinal perforations: Twenty-six year experience. World J Surg 2007;31: Kaul BK. Operative management of typhoid perforation in children. Int Surg 1975;60: Badejo OA, Arigbabu AO. Operative treatment of typhoid perforation with peritoneal irrigation: A comparative study. Gut 1980;21: Wexner SD, Taranow DA, Johansen OB, Itzkowitz F, Daniel N, Nogueras JJ, et al. Loop ileostomy is a safe option for fecal diversion. Dis Colon Rectum 1993;36: Capoor MR, Nair D, Chintamani MS, Khanna J, Aggarwal P, Bhatnagar D. Role of enteric fever in ileal perforations: An overstated problem in tropics? Indian J Med Microbiol 2008;26: Archampong EQ. Tropical diseases of the small bowel. World J Surg 1985;9: Lizarralde E. Typhoid perforation of the ileum in children. J Pediatr Surg 1981;16: Archampong EQ. Typhoid ileal perforations: Why such mortalities? Br. J Surg 1976;63: Chatterjee H, Pai D, Jagdish S, Satish N, Jayadev D, Srikanthreddy P. Pattern of nontyphoid ileal perforation over three decades in Pondicherry. Trop Gastroenterol 2003;24: Jain BK, Arora H, Srivastava UK, Mohanty D, Garg PK. Insight into the management of non-traumatic perforation of the small intestine. J Infect Dev Ctries 2010;4: Gupta S, Kaushik R. Peritonitis - the Eastern experience. World J Emerg Surg 2006;1: Aziz A, Sheikh I, Jawaid M, Alam SN, Saleem M. Indication and complications of loop ileostomy. J Surg Pak 2009;14: Eggleston FC, Santoshi B, Singh CM. Typhoid perforation of the bowel. Experiences in 78 cases. Ann Surg 1979;190: Carmeli Y, Raz R, Schapiro JM, Alkan M. Typhoid fever in Ethiopian immigrants to Israel and native-born Israelis: A comparative study. Clin Infect Dis 1993;16: Ahmed HN, Niaz MP, Amin MA, Khan MH, Parhar AB. Typhoid perforation still a common problem: Situation in Pakistan in comparison to other countries of low human development. J Pak Med Assoc 2006;56: Santillana M. Surgical complication of typhoid fever: Enteric perforation. World J Surg 1991;15: Abantanga FA. Complications of typhoid perforation of the ileum in children after surgery. East Afr Med J 1997;74: Akinoglu A, Bilgin I. Tuberculous enteritis and peritonitis. Can J Surg 1988;31: Veeragandham RS, Lynch FP, Canty TG, Collins DL, Danker WM. Abdominal tuberculosis in children: Review of 26 cases. J Pediatr Surg 1996;31: How to cite this article: Shah S, Gandhi JP. Role of ileostomy in enteric perforation. IJSS Journal of Surgery. 2015;1: Source of Support: Nil, Conflict of Interest: None declared. IJSS Journal of Surgery January-February 2015 Volume 1 Issue 1 15