typhoid perforation
Introduction
Introduction to intestinal typhoid perforation Intestinaltyphoid with perforation is a serious complication of typhoid fever, with an incidence of 2% to 6%. Patients undergoing surgery have received timely surgical treatment even after perforation, but because they are at the peak of disease development, the body is very weak, the resistance is low, and the general condition is poor. In addition, surgical trauma, postoperative typhoid fever continues to exist, resulting in Mortality is still high (20% to 30%), so there is still a need to be aware of this disease and be alert. basic knowledge The proportion of illness: 0.037% Susceptible people: no specific people Mode of infection: non-infectious Complications: shock
Cause
Causes of intestinal typhoid perforation
Water pollution (30%):
Most of the typhoid bacilli that enter the digestive tract with contaminated water or food are killed by gastric acid. When the number of bacteria entering the body exceeds 100,000, or the gastric acid is reduced due to certain diseases, it is possible for some typhoid bacilli to survive, through the stomach acid. After the intestinal bacillus, which has not been killed by the barrier, enters the small intestine, it penetrates into the intestinal lymphatic tissue through the epithelial cells or interstitial space of the small intestinal mucosa, is swallowed by phagocytic cells and proliferates in it, and some bacteria multiply through the lymphatic vessels into the mesenteric lymph nodes. Entering the blood through the thoracic duct causes bacteremia, and the typhoid bacillus enters various organs of the body, such as liver, spleen, kidney, gallbladder, etc., and multiplies in it, and the bacteria phagocytized by phagocytic cells re-enter the blood to cause the second bacteremia. Symptoms, activation of sensitized lymphocytes produces strong delayed allergic reactions.
Ulcer invasion (35%):
The pathological changes of enteric typhoid mainly occur in the terminal ileum within 100cm from the ileocecal valve. The aggregated lymph nodes are swollen due to congestion, edema and hyperplasia. The intestinal wall ulcers occur with the necrosis of the lymph nodes. The invasion of blood vessels can cause intestinal bleeding. When the ulcer reaches the muscular layer and the serosa layer deep, once the pressure in the intestinal lumen is increased or the peristalsis is hyperthyroidism, it is easy to cause acute perforation.
Prevention
Enteric typhoid perforation prevention
Patients with typhoid fever are at the peak of disease infection during the surgical treatment. The patient's body, clothing and patient's excretion are highly contagious. They should be disinfected and isolated. According to the principle of isolation of intestinal infectious diseases. Disinfect the patient's excretion until the isolation period is removed, and prevent and treat recurrence and reburning of typhoid. Timely discovering and detecting carriers, preventing chronic carriers from engaging in work should not be carried out, and medical observation should be carried out on people who are in close contact with typhoid patients to reduce the spread of disease.
Complication
Enteric typhoid perforation complications Complications
The symptoms of poisoning caused by typhoid bacillus are obvious, which may lead to toxic shock and multiple organ dysfunction.
Symptom
Intestinal typhoid perforation symptoms common symptoms nausea reaction slow constipation relaxation heat intestinal bleeding intestinal perforation persistent pain expression indifference cold sweat tinnitus
Intestinal typhoid perforation is also accompanied by typhoid fever in summer and autumn. According to statistics, the incidence of typhoid perforation in typhoid fever is generally around 5%, and 60% to 70% of perforation occurs in the second or third week of the disease. Within 10% to 20% occur in the first week, and individual occurrences occur after the 4th week or the 4th week. Typical clinical manifestations include:
1. Symptoms of typhoid fever: typical intestinal typhoid fever has persistent high fever, abdominal pain, constipation or diarrhea, hepatosplenomegaly, relatively slow pulse and leukopenia. The typical clinical process can be divided into 5 phases, namely:
(1) Incubation period: 3 to 60 days, usually 8 to 14 days. The length of the incubation period varies with the size of the infection dose and the immunity of the body. The number of bacteria is large, the virulence is strong, and the incubation period of the body is low. Water-borne infections consume less bacteria and have a longer incubation period.
(2) Initial stage: equivalent to the first week of the disease course, usually the onset is more insidious, the earliest symptom is fever, the body temperature rises stepwise, reaching 39 °C ~ 40 °C within 5 to 9 days, often accompanied by general malaise, chills, Muscle soreness, loss of appetite, bloating, constipation or mild diarrhea, sore throat, cough, etc.
(3) Extreme period: equivalent to the second to third week of the disease course, the typical performance of typhoid fever often occurs. In this period, about 5% of patients have intestinal perforation and intestinal bleeding.
1 high fever: more than the heat retention type, high fever continues to retreat, especially in patients with drug-resistant typhoid fever is very common, a small number of patients with relaxation heat or irregular type, fever for 10 to 14 days.
2 Relatively slow pulse: The body temperature of typhoid patients appears relatively slow pulse at 38 °C ~ 39 °C, which is one of the representative performances of typhoid fever patients. The pulse of healthy people increases with the increase of body temperature, generally according to the increase of body temperature. A simple method of estimating the pulse speed by 10 times per minute at 1 °C.
(4) Remission period: equivalent to the fourth week of the disease course, the body temperature gradually decreased from the third weekend to the fourth week and reached normal. The condition began to improve, and the body temperature of the relaxation type was gradually decreased, and various symptoms gradually decreased. The appetite improved.
(5) Recovery period: about 5 weeks into the recovery period, the clinical symptoms precede the pathological recovery, the patient's body temperature returns to normal, the symptoms gradually reduce or disappear, the appetite increases significantly, there is hunger, and there may be sweating, except In addition to the above typical forms of onset, some patients have atypical symptoms, some have pneumonia, and have symptoms of sepsis 1 to 2 days after onset. They may have symptoms and signs of large leaf pneumonia. Bacillus, some in the form of arthritis, similar to the early stage of rheumatic fever, and some with pleurisy, typhoid nephritis, cholecystitis, deep jaundice onset.
2. Intestinal typhoid perforation symptoms: Intestinal perforation is the most serious complication of typhoid fever, often occurs in the second to third weeks of symptoms, mostly in patients with severe abdominal pain, abdominal distension, abdominal tenderness, and some in treatment A few days later, when the patient began to appear to be improved, the patient suddenly appeared perforation. After the perforation occurred, the patient complained of pain in the right lower quadrant, accompanied by nausea, vomiting, rapid pulse, cold sweat, temporary decrease in body temperature (shock period), etc. After 1~ After 2 hours, abdominal pain and other symptoms can be relieved slightly (quiet period). Soon, the patient developed persistent abdominal pain, painful expression, and rapid rise in body temperature. The body found that the symptoms of peritoneal inflammation throughout the abdomen were still evident in the right lower abdomen. Tenderness, rebound tenderness, muscle tension, and liver dullness shrink or disappear.
Examine
Examination of intestinal typhoid perforation
1. Blood routine: The white blood cell count is increased on the original basis, more than 1/3 of the patients exceed 10 × 109 / L, and individual can reach more than 20 × 109 / L (peripheral inflammation period).
2. Serum typhoid agglutination test (Fat Darwin's test) O antibody titer of 1:80 or more, H antibody titer of 1:160 or more has diagnostic value.
3. Bacteriology culture: Found typhoid bacillus.
4. X-ray examination: more than 70% of patients can see underarm free gas.
5. Diagnostic abdominal puncture can assist in diagnosis.
Diagnosis
Diagnosis and identification of intestinal typhoid perforation
Diagnostic criteria
Diagnosis of intestinal typhoid perforation is often affected by some factors, most patients have a late treatment, longer perforation, severe peritonitis, obvious symptoms of poisoning or toxic shock, relatively slow response, due to mental factors, patients often Can not clearly describe the condition, only mild abdominal wall tenderness and mild muscle tension are found during physical examination, it is difficult to make typhoid diagnosis, right lower abdominal signs appearing in typhoid typhoid, often confused with acute appendicitis, perforation symptoms and signs The performance is not typical.
(1) Whether living in an infected area, whether there is history of exposure to typhoid fever.
(2) Unexplained persistent high fever (38 ° C ~ 40 ° C) accompanied by headache, loss of appetite, abdominal distension, colic, diarrhea, consider the possibility of intestinal typhoid.
(3) Whether the characteristic clinical manifestations and specific laboratory tests of typhoid fever have a low white blood cell count and a positive fat reaction.
Differential diagnosis
The symptoms and signs of peritoneal inflammation after perforation of intestinal typhoid are not significantly different from those of common intra-abdominal hollow organs. Therefore, in the differential diagnosis, except for diseases with typical clinical processes, such as appendicitis, perforation of ulcer disease, acute suppurative cholecystitis With perforation, perforation of hemorrhagic necrotic enteritis, etc., it is more important to follow the clinical manifestations and laboratory tests unique to typhoid fever, such as persistent high fever, abdominal pain, constipation or diarrhea, hepatosplenomegaly, relative slow pulse and leukopenia As a basis for identification with other diseases, in the laboratory test, the serum antibody reaches the O antibody titer of 1:80 or more, and the H antibody titer of 1:160 or more has diagnostic value, especially from the blood, bone marrow and feces of patients. The typhoid bacillus has a decisive significance for identification with other diseases.
