Khalid Javaid  ( Department of Surgery, Punjab Medical College, Faisalabad. )
Riaz Hussain Dab  ( Department of Surgery, Punjab Medical College, Faisalabad. )
Altaf Hussain Rathore  ( Department of Surgery, Punjab Medical College, Faisalabad. )
Guizar Ahmad  ( Department of Surgery, Punjab Medical College, Faisalabad. )

Forty cases of typhoid ileal perforation were treated surgically in three years. Chioramphenicol and gentamycin were given to 20 patients, while the remaining 20, received Metronidazole additionally. The mortality rate was 60 percent in the first and 40 percent in the second group. (JPMA 46:49, 1996).

Intestinal perforation is a common surgical complica­tion in enteric fever. It occurs in 0.5¹ to 33.6%² of patients with a mortality of 7.9 to 57%^3,4. The management of intestinal perforation in entenc fever has long been a controversial subject. Huckstep⁵ strongly advocated conservative manage­ment, while more recently, there has been a consensus in favour of surgical intervention^6-8.
Chioramphenicol has been the antibiotic of choice for typhoid perforation since 1949. It is still in use for surgical prophylaxis. Despite the drug, the mortality rate after surgery is high. Kurlberg and Frisk⁹ recommended an addition of gentamscin and metronidazole to chioramphenicol to im­prove the prognosis. A study was undertaken to compare the results of two.,groups of patients with typhoid perforation freat&i%s ith either chloramphenicol and gentamy cin or metronizidazole alongwith the tw antibiotics.

ycases of intestinal perforation were treated surgi­cally at Victoria Hospital, Bahawalpur over a period of three years. Twenty were given the standard regime of chioram­phenicol and gentamycin and 20 received chloramphenicol, gentamycin and metronidazole. Every case was promptly resuscitated and investigated pre-operatively. All were oper­ated in emergency and theRerforation was closed in two layers with polygalactin sutures¹¹.

There were 32 males and 8 females. Most of the patients were in the age group 11 to 20 years with an average of 19.3 years.Majority of perforations occurred in the first and second week of fever and most of them presented more than 3 days after perforation. The widal test was positive in 32 and negative in 8 cases. Biopsy was carried out in 33 cases, 27 had histologically massive areas of necrosis, degeneration and mononuclear and plasma cell infiltration. Six showed no histological change.
All perforations were situated within 2 feet from the ileocaecal junction. The size of the perforation varied from 2 mm to 25 mm in diameter. Out of 40, 20 patients died representing an overall mortality rate of 50%. Mortality was 40%, when metronidazole was added to the standard treatment and 60% in those treated with chloramphenicol and gentamy­cin alone. Recurrence of perforation, faecal fistula and toxaemia were the main causes of death.

Typhoid ileal perforation is a serious surgical emer­gency where peritoneal cavity is flooded with the intestinal contents along with the typhoid bacilli, coliform aerobic and anaerobic micro- organisms. Antibiotic against salmonella only is not enough for these cases. For better results, chemotherapy against coliform and anaerobes is also re­quired¹². Thomas et al¹³ recommended addition of metromda­zole for typhoid perforation for better results. This study confirms previous reports^10,14 that adding metronidazole to gentamycin and chioramphenicol improves the prognosis in intestinal perforation due to typhoid.

1. Webb-Johnson, A.E. Complication oftyphoid fever. Lancet, 1917;8:813-15.
2. Olurin. E.0.. Ajayi, 0.0 and Bohrer, S.P. Typhoid perforation, J.R. Coil. Surg. Edinb., 1972:17;353-63.
3. Sitaram, V., Moses, B.V., Khanduri, P. et a!. Typhoid ileal perforation and retrospective study. Ann, R. Coil. Surg. Engi., 1990;72:347-9.
4. Akoh, J.A. Prognostic factors in typhoid perforation. East Afr. Med. J., 1993;70:1 8-21.
5. Huckstep, R.L. Recent advances in the surgery of typhoid fever. Ann. R. Coil. Surg. Engi., 1960;26:207-230.
6. Rathore, A.H., Khan, I.A. and Saghir, W. Prognostic indices of typhoid perforation. Ann. Trop. Med. Parasitology, 1987;81 :283-9.
7. Meier, D.E., Imediegwu, 0.0. and Tarpley, J.L. Perforated typhoid enteritis. Am. 3. Surg., 1989;157:423-7.
8. Wilson, S. 3., Green, R., Britto, D. et a!. Surgical complication of typhoid fever. Trop. Doct., 1993;23:133-4.
9. Gibney,E.J. Typhoid perforation. Br. J. Surg., 1989;76:887-9.
10. Kurlberg, G. and Frisk, B. Factors reducing mortality in typhoid ileal perforation. Trans. R. Soc. Trop. Med. Hyg., 1991 ;89:255-6.
11. Singh, K.P., Singh, K. and Kohli, J.S. Choice of surgical procedures in typhoid perforation. J. Indian Med. Assoc., 1991 ;89:255-6.
12. Richcns, J. Management of bowel perforation in typhoid fever. Trop. Doct., 1991;21:149.152.
13. Thomas, S. S., Mammen, K. J. and Enggleston, F.C. Typhoid perforation, Trop. Doct., 1990;20: 126-8.
14. Mock, C.N., Amaral, 3. and Visser, L.E. Improvement in survival from typhoid ileal perforation. Ann. Surg., 1992;21 5:244-9.