Typhoid Peritonitis: Causes, Symptoms, Diagnosis, Treatment, and Prevention

1A07.0 Typhoid Peritonitis

Overview: Typhoid peritonitis is a severe and potentially life-threatening complication of typhoid fever, caused by Salmonella enterica serotype Typhi (S. Typhi). Peritonitis refers to inflammation of the peritoneum, the thin layer of tissue that lines the abdominal cavity and covers the abdominal organs. In typhoid peritonitis, the infection spreads from the intestines to the peritoneum, often as a result of an intestinal perforation (a hole or rupture in the intestinal wall). This condition requires urgent medical attention and treatment to prevent severe complications, including septic shock, organ failure, and death.

Typhoid peritonitis is relatively rare today, as early diagnosis and effective antibiotic treatment of typhoid fever have significantly reduced its incidence. However, when it does occur, it is a medical emergency, often necessitating both surgical intervention and intensive antibiotic therapy.

Etiology: Typhoid peritonitis develops as a consequence of typhoid fever caused by S. Typhi, a bacterium transmitted via the fecal-oral route through contaminated food, water, or hands.

1. Bacterial Invasion: In the early stages of typhoid fever, S. Typhi infects the gastrointestinal tract, typically causing symptoms like fever, abdominal pain, and diarrhea. In some cases, the bacteria can invade deeper layers of the intestine, leading to inflammation, ulceration, and, eventually, intestinal perforation.

2. Perforation and Peritonitis: Once the intestinal wall is perforated, the bacteria, along with gut contents (such as fecal material), spill into the sterile peritoneal cavity. This leads to peritonitis, which causes widespread abdominal inflammation and can result in infection of the surrounding tissues.

Symptoms: The symptoms of typhoid peritonitis can develop suddenly and progress rapidly. Early signs of typhoid fever may worsen, and new symptoms related to the abdominal cavity emerge:

• Severe Abdominal Pain: The most prominent symptom is sudden, severe abdominal pain, which is typically generalized and worsens with movement or pressure on the abdomen.
• Abdominal Tenderness: The abdomen becomes tender to the touch, and patients may develop abdominal distention (swelling).
• High Fever: Persistent high fever, often with chills, may continue to rise, worsening the patient's condition.
• Nausea and Vomiting: These are common and can be severe, often resulting in dehydration.
• Signs of Sepsis: As the infection spreads, symptoms of sepsis may develop, such as rapid heartbeat, low blood pressure, and confusion.
• Bloating and Guarding: Abdominal bloating due to fluid buildup in the peritoneum, and muscle guarding (the reflex tightening of abdominal muscles to prevent pain) are common signs.
• Rapid Breathing: This can be due to severe abdominal pain or the development of a systemic infection.
• Changes in Mental Status: Mental confusion or delirium can occur, particularly as the infection worsens, indicating possible septic shock.

Diagnosis: Diagnosing typhoid peritonitis involves clinical evaluation, laboratory tests, and imaging studies:

1. Clinical Examination: A thorough physical exam often reveals signs of peritonitis, including abdominal tenderness, guarding, and distention. Patients with typhoid peritonitis usually present with high fever and signs of sepsis, such as hypotension (low blood pressure) and tachycardia (rapid heart rate).

2. Blood Cultures: S. Typhi can often be isolated from blood cultures, confirming the bacterial cause of the infection.

3. Stool or Peritoneal Fluid Culture: If there is suspicion of intestinal perforation, cultures of peritoneal fluid obtained during surgery or diagnostic tapping may help confirm the diagnosis.

4. Imaging Studies: Abdominal X-rays or CT scans can reveal signs of intestinal perforation, such as the presence of free air in the peritoneal cavity (indicating perforation). A CT scan is particularly useful for identifying the location of the perforation and assessing the extent of peritoneal involvement.

5. Widal Test: Although the Widal test can detect antibodies against S. Typhi, it is not specific and may not always confirm a diagnosis of typhoid peritonitis.

Treatment: The treatment of typhoid peritonitis requires a multi-faceted approach involving both medical and surgical interventions:

1. Antibiotic Therapy:

   • Broad-spectrum antibiotics are given immediately after the diagnosis is suspected to control the infection. The choice of antibiotics will often be guided by blood and peritoneal fluid cultures to determine the most effective treatment for the specific strain of S. Typhi.
   • Common antibiotics include ceftriaxone, azithromycin, and fluoroquinolones (e.g., ciprofloxacin), although antibiotic resistance, particularly to fluoroquinolones, is a growing concern.
   • In severe cases, combination therapy may be required to treat multidrug-resistant S. Typhi.

2. Surgical Intervention:

   • Emergency surgery is typically required to treat intestinal perforation. The perforated part of the intestine is repaired or removed to prevent further spillage of bacteria and fecal material into the peritoneal cavity.
   • In some cases, drainage of the peritoneal cavity may be necessary to remove infected material and prevent further abscess formation.

3. Supportive Care:

   • Fluid resuscitation to restore lost fluids and electrolytes, especially if there is dehydration from vomiting or diarrhea.
   • Pain management using analgesics to relieve abdominal pain.
   • Nutritional support and intravenous feeding may be required in severe cases to help the patient recover.
   • Intensive care may be necessary for patients who develop septic shock, with monitoring of vital signs and organ function.

Prevention: Preventing typhoid peritonitis primarily involves controlling the spread of S. Typhi and ensuring timely treatment of typhoid fever before complications arise:

1. Vaccination: Typhoid vaccines (oral and injectable) are recommended for people traveling to regions with endemic typhoid fever, healthcare workers, and others at high risk.

2. Improved Sanitation: Ensuring access to clean drinking water and better sanitation facilities can reduce the risk of S. Typhi transmission. This includes practicing good hand hygiene, particularly after using the toilet and before handling food.

3. Food Safety: Avoid consuming raw or undercooked food, especially in areas where sanitation is poor. Ensure that water is boiled or treated before drinking.

4. Early Diagnosis and Treatment of Typhoid Fever: Timely diagnosis and proper antibiotic treatment of typhoid fever are crucial to prevent the progression to complications like typhoid peritonitis.

Prognosis: The prognosis of typhoid peritonitis depends on the severity of the condition, the timeliness of treatment, and the patient’s overall health. Without treatment, typhoid peritonitis can be fatal, with high mortality rates due to septic shock and multi-organ failure. However, with prompt surgical intervention and appropriate antibiotic therapy, many patients recover. The fatality rate has significantly decreased with advances in medical care, but the condition remains serious and requires immediate attention.

The above information is provided as general reference material; please be sure to consult a specialist for accurate diagnosis and treatment tailored to your individual situation.