Indexing Title:   DCHUA’s Medical Anecdotal Report [04-1]

MAR Title: Patient with Perforated Typhoid Ileitis

Date of Medical Observation: April 24, 2004

Narration:

20/M at ER, endorsed by from-duty group as booked for appendectomy.  My typical disregard for the hurried entries in the patient’s ER chart led to unrevealed (throughout all the notes, from the receiving department, to all the doctors who saw the patient) two week history of fever.

Preop assessment, perforated typhoid ileitis with generalized peritonitis.  By Departmental protocol of confirming acute surgical peritonitis by PE, and by pattern recognition, a confirmatory CXR was not necessary.

To reconcile commonly held view that pneumoperitoneum always seen, my misconception that only PUDs have enough air, textbook statistics that 10-35% would initially be negative, I ordered for a CXR that showed distinct subdiaphragmatic air.

Patient was thin enough that I achieved enough exposure by just an infraumbilical incision, instead of the routine outright xiphoid to pubis incision.  (Actually, this was just my second operative exposure to such a case, in two weeks, and in all my life. The first was a similarly overlooked patient whose illness started after the patient worked on a certain water well system, with many of his colleagues falling ill.)

Smallest amount of abnormal-looking perforation edge removed.  Gently removed as much fibrinous exudates as I could and irrigated the peritoneal cavity with an atypically large amount of NSS until clear.  Closing the fascia with atypical PDS (level 1 evidence) atypically without interlocking (level 1), I irrigated the subcutaneous again with an atypically large amount of NSS, atypically without povidone-iodine in it.

Patient atypically started on clear liquids upon return to the wards.  Atypically added Metronidazole late (level 2 at least) when the patient was already tolerating much diet.  No wound discharge noted.  Patient went home 4 days post-op afebrile.

Time will tell if I did miss anything, or if the following insights remain true.

Insights (Discovery, Stimulus, REINFORCEMENT):

 Reinforcements:

A patient booked for a case is not necessarily such a case

Proper disregard for the hurried entries in the patient’s ER chart

Departmental protocol of confirming acute surgical peritonitis by PE

Pneumoperitoneum in perforated ileum

Minimal but safe procedure

Profuse peritoneal and subcutaneous toilet

No unnecessary routines in OR (interlocking, betadine in irrigant)

Early feeding feasible

Starting anti-enterobacteriacea early and anti-anaerobes late

Typhoid fever lysis in 4-7 days

Stimulus:

Pneumoperitoneum detection rate in Filipino perforated typhoid ileitis

Subcutaneous irrigation: copious plain vs. limited povidone-iodine solution

Is starting metronidazole late equally effective in preventing abscess?

Discovery:

Not my sole observation that such cases suddenly became more common.