Typhoid Ulcers
Typhoid Ulcer

Video Endoscopic Sequence 1 of 27.

Typhoid Ileocolitis

Case of multiple Typhoid Ulcers of the Colon and Terminal ileum in which a hemoclip is placed to an ulcer of the ilium with suspicion of being perforated.

This is a 17 year-old, female, presenting a recurrent fever of 100.4 to 104 Fahrenheit of 3 weeks with diffuse abdominal pain, general malaise, severe headache, tachycardia and signs of hypotension, elevated hepatic enzymes, leukogram with leukopenia and neutrophilia.

On admission She was febrile with 102.2 °F, had a heart rate of 150 beats per minute (bpm), and a blood pressure of 80/50 mmHg. Her hemoglobin was 8.1 g/dl.

There was diffuse abdominal tenderness on palpation, but no rebound or guarding.

Abdominal ultrasound reports thickening of the wall of intestinal loops at the level of the right flank. Without detailing other alterations in the study.

She received an additional six days of intravenous ceftriaxone as well as ciprofloxacin. The patient was discharged stable after completing her course of antibiotics and continuing with oral ciproflaxacin and Cefixime for 10 adicional days on ambulatory basis.

Typhoid fever is caused by enteroinvasive Gram-negative organism Salmonella typhi. The well-known complications of typhoid fever are intestinal haemorrhage and perforation. In the pre-antibiotic era, these complications were quite common, but in the current antibiotic era the incidence of these complications is on the decline. We report a case of a patient with typhoid fever who have haematochezia and was found to have multiple ulcers caecal ulcer on colonoscopy. She was managed successfully with Irrigate ice water through the working channel and there was no rebleed.

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Typhoid Ulcer

Video Endoscopic Sequence 2 of 27.

Typhoid Ulcers of the Rectum

Serious complications of typhoid ulcerations are severe hemorrhage when an ulcer erodes into a blood vessel, and transmural perforation leading to peritonitis. Colonoscopic diagnosis can be helpful in some cases for an early diagnosis, favoring more quick treatment of typhoid fever, with lower number of complications.

Typhoid fever:
Sometimes known as enteric fever, is a life threatening illness caused by Salmonella typhi sometimes called Salmonella enterica serotype Typhi or S. paratyphi
Infects from 20 to 30 million people a year, mostly in the developing world In industrialized countries, it is usually encountered in travelers.

Intestinal haemorrhage is one of the known complications of typhoid fever which usually occurs at the third week of illness. Bleeding occurs from the typhoid ulcers when the adjacent vessels are eroded. The frequent site of intestinal haemorrhage is the terminal ileum and bleeding from a caecal ulcer is rather uncommon. Literature regarding colonoscopic findings in typhoid ulcer bleeding is rare.

Typhoid perforation. A review of the literature since 1960.Colonoscopic manifestations of typhoid fever with lower gastrointestinal bleeding.

 

 

Typhoid Ulcer

Video Endoscopic Sequence 3 of 27.

Typhoid Ulcer of the descending Colon

Intestine perforation is one of the most dreaded and common complication of typhoid fever remarkably so in developing world; it usually leads to diffuse peritonitis, requiring early surgical intervention. Despite various measures such as safe drinking water supply and safe disposal of waste, intestinal perforation from salmonellosis remains the most common emergency surgery performed. The incidence continues to rise, so also the mortality, despite new antibiotics and improvement in surgical technique. More disturbing is that we now see increasing number of ileal perforations and colonic involvement.

Intestinal perforation is a common cause of peritonitis necessitating emergency surgical intervention. Perforation of the bowel from typhoid perforation is a serious abdominal complication. The prevalence of typhoid fever is gradually decreasing worldwide;

 

Typhoid Ulcer

Video Endoscopic Sequence 4 of 27.

Typhoid Colitis

Although, intestinal hemorrhage is the most common complication of typhoid fever yet intestinal perforation continues to be the most frequent cause of its high morbidity and mortality. In general, hemorrhage and perforation occur in the terminal ileum secondary to necrosis of Peyer's patches at 2-3 weeks after the onset of the disease. Mortality rates of typhoid intestinal perforation (TIP) cases are reported to be between 5% to 62%.[ Perforation of terminal ileum is a cause for acute obscure peritonitis, heralded by exacerbation of abdominal pain associated with tenderness, rigidity and guarding, most pronounced over right iliac fossa. However, for many patients in a severe toxic state, there may be obscured clinical features with resultant delays in diagnosis and adequate surgical intervention. While early surgical procedures are regarded as definitive treatments along with pre-operative resuscitation and post-operative intensive care, the methods that should be used in surgery are still contentious. In the present case report, we present a rare case of 24 perforations in the terminal ileum and cecum of a patient. To the best of our knowledge, this is the 3rd highest number of intestinal perforations from typhoid in an adult patients reported in the literature.

Typhoid Ulcer

Video Endoscopic Sequence 5 of 27.

Typhoid Ulcers of the Cecum

Typhoid ileal perforation still remains a very severe condition in tropical countries. Its incidence ranges from 0.9% to 39%, with a mortality rate, which remains very high. Primarily, the mortality and the morbidity rate do not depend on the surgical technique, but rather on the general status of the patient, the virulence of the salmonella and the duration of disease evolution before surgical treatment. That is why, it is so important to provide adequate pre-operative management associating aggressive resuscitation with antibiotic therapy. In the literature, it is usually advocated that the last 60 cm of the ileum presents a high concentration of Peyer's patches whose infection is a source of intestinal perforation.

 

Typhoid Ulcer

Video Endoscopic Sequence 6 of 27.

Typhoid Ulcers of the Ascending Colon

Typhoid fever with perforation is best managed by early surgical intervention. Various surgical options available are simple primary closure, primary closure with omental patch, resection and anastomosis, and closure with ileo-transverse colostomy. Fecal fistula, which is the most common complication of enteric perforation, may occur either because of anastomotic dehiscence, reperforation or different site of perforation. Simple primary closure is still the procedure of choice as it is quick and cost-effective. However, some of the studies showed that the development of fecal fistula and mortality is unrelated to the operative procedure.

Despite global scientific development typhoid fever and its complications continue to be a great health problem especially in developing country. The management of salmonella enteric perforation needs appropriate early surgical intervention, effective resuscitation in the pre-operative period, post-operative care, and use of proper antibiotics. In our study, there is no evidence of decreased immunity of patient, so increased virulence of bacteria might be probable cause of such complication of typhoid enteritis. The key to improved survival in this deadly disease lies not in a better operation or improved perioperative care, but in the prevention of typhoid fever by providing safe drinking water and improved sanitation methods for all of the global community.

 

Typhoid Ulcer

Video Endoscopic Sequence 7 of 27.

Typhoid Ulcers of the Cecum

Thus, typhic lesions in the digestive system can lead to perforations, hemorrhages, invaginations, appendicitis, cholecystitis, liver abscesses, abscesses and ruptures of the spleen, pancreatitis and mumps.

 

 

Typhoid Ulcer

Video Endoscopic Sequence 8 of 27.

Typhoid Ulcers of the Cecum

It has been reported in the world literature that the rate of intestinal perforation varies from 2.8% to 10.5% and that overall, developing countries and Africa in particular, have annual rates of typhoid perforation of 540 and 1020 per 100 000 respectively. During the surgery, ileus, caecum, and proximal large intestine should be examined for ulcerations or perforations. The intestinal perforation arises from the necrosis of the Peyer's plates at the antimesenteric border.

Typhoid Ulcer

Video Endoscopic Sequence 9 of 27.

Typhoid Ulcers of the Cecum

The most frequent location of perforation or ulceration is on the antimesenteric side and at approximately 80 cm. of the ileocecal valve.

 

Typhoid Ulcer

Video Endoscopic Sequence 10 of 27.

Deep Typhoid Ulcer, muscularis mucosae is showing

 

 

Typhoid Ulcer

Video Endoscopic Sequence 11 of 27.

Another image and video of deep typhoid ulcer of the ascending colon near the cecum.

 

 

 

Typhoid Ulcer

Video Endoscopic Sequence 12 of 27.

Typhoid Ulcers of the Cecum of different morphology

 

Typhoid Ulcer

Video Endoscopic Sequence 13 of 27.

Multiple ulcers are displayed in the iiocecal valve


Typhoid Ulcer

Video Endoscopic Sequence 14 of 27.

Multiple ulcers are displayed in the iiocecal valve

 

 

 

 

Typhoid Ulcer

Video Endoscopic Sequence 15 of 27.

Cecum: looking around the hole of the appendix displaying several ulcers

 

 

Typhoid Ulcer

Video Endoscopic Sequence 16 of 27.

Terminal Ileum Typhoid Ulcer

Ileocolonoscopy video showing multiple ulcers of varying sizes involving the Rectum, sigmoid, descending, ascending colon, caecum and terminal ileum. 

 

 

 

 

 


Typhoid Ulcer

Video Endoscopic Sequence 17 of 27.

Terminal Ileum Typhoid Ulcer

An ulcer with a central hole with suspicion of being formed an evolving perforation.

The most serious and relatively frequent complication, the one most feared by the doctor and the one that by its numerous operative failures puts to the test the temper of the surgeon; This is the typhic intestinal perforation.

 

 

 

Typhoid Ulcer

Video Endoscopic Sequence 18 of 27.

Terminal Ileum Typhoid Ulcer, also observed lymphoid hyperplasia which is normal in this region.

 

Typhoid Ulcer

Video Endoscopic Sequence 19 of 27.

Terminal Ileum Typhoid Ulcer

 

 

Typhoid Ulcer

Video Endoscopic Sequence 20 of 27.

An hemoclip is placed in the ulcer with suspected perforation.

 

 

An hemoclip is placed in the ulcer with suspected perforation.

Typhoid Ulcer

Video Endoscopic Sequence 21 of 27.

The hemoclip is placed

In typhic intestinal perforation there are three main symptoms, which are: Spontaneous pain on abdominal palpation. Resistance of the abdominal wall (guarding). and Pneumoperitoneum.

The most lethal complications of typhoid fever is ileal perforation, which affects especially young

 Information was obtained on a total number of 1,990 cases of typhoid perforation in 66,157 patients with typhoid fever, published in 52 reports all over the world. The overall frequency of intestinal perforation in typhoid fever was 3% with an overall mortality rate of 39.6%. In an endemic area of typhoid fever, the diagnosis of typhoid perforation should be made on physical examination. Surgery is perferable to medical treatment.

Typhoid perforation. A review of the literature since 1960.Typhoid perforation. A review of the literature since 1960.

 

Typhoid Ulcer

Video Endoscopic Sequence 22 of 27.

The hemoclip has been placed closing the small hole

After the colonoscopy, the evolution of the patient was excellent, the abdominal pain decreased considerably due to the effect of the ice water that was irrigated in several ulcers and the hemoclip that closed a small hole in one ulcer of the terminal ilium. The enterorrhagia decreased considerably.

Apparently this hemoclip helped her a lot to improve the clinical picture and in this way the patient is saved from the dreaded perforation and thus from a complicated surgery.more still his life is saved.

We have not found in the medical literature previously reported case of closing an ulcer tifica in phase of perforation with a hemoclip for which we believe that we are the first.

Typhoid perforation of the intestine.Typhoid perforation of the intestine.

 

Ulceras Tificas

Video Endoscopic Sequence 23 of 27.

Multiple ulcers of the cecum

 

Typhoid Ulcer

Video Endoscopic Sequence 24 of 27.

One of the ulcers of the descending colon is displayed

Perforations have been reported in various parts of the digestive tract.

 

 

Typhoid Ulcer

Video Endoscopic Sequence 25 of 27.

Multiple biospies were taken

 

Typhoid Ulcer

Video Endoscopic Sequence 26 of 27.

Typhoid Ulcer ulcers of the rectum

 

 

Typhoid Ulcer

Video Endoscopic Sequence 27 of 27.

Rectum in Rectoflexión, there are multiple ulcers.

 

Typhoid Ulcer

Video Endoscopic Sequence 1 of 12.

Typhoid ulcers causing life-threatening bleeding

This is a 16 year-old female, presenting with massive enterorrhagia, The clinical picture had been a recurring process of continuous fever up to 104 Fahrenheit and headaches of two weeks.

She was found unconscious and It is hospitalized, after correcting the hypovolemic shock with blood transfusion that was up to 5 units.
A colonoscopy is performed by finding abundant blood remains in the entire colon, finding in the cecum multiple irregular ulcers as well as in the terminal ileum.

She was managed successfully with Irrigate ice water through the working channel and there was no rebleed.

We report a case of a patient with typhoid fever who developed severe haematochezia and was found to have multiple cecal ulcers and also multiple terminal ileum ulcers on colonoscopy. She was managed successfully with conservative measures without endotherapy and there was no rebleed. The patient was discharged six days after admission.
It was documented infection with S. tiphy in blood cultures and histopathology.

Ulcerations generally occur in the terminal ileum, cecum and the ascending colon, and rarely in the left side of the colon

The well-known complications of typhoid fever are intestinal haemorrhage and perforation. In the pre-antibiotic era, these complications were quite common, but in the current antibiotic era the incidence of these complications is on the decline.


Typhoid ulcers causing life-threatening bleeding

Video Endoscopic Sequence 2 of 12.

Typhoid ulcers causing life-threatening bleeding

Multiple ulcers in the cecum

Typhoid fever and paratyphoid fever is a systemic infection caused by Salmonella enterica, including S. enterica serotype Typhi (S. typhi) and serotype Paratyphi (S. paratyphi). Enteric fever is a faecal-oral transmissible disease and thus occurs in an environment with overcrowding, poor sanitation and untreated water.

Complications occur in 10 to 15% of patients and are particularly likely in patients who have been ill for more than two weeks. Many complications have been described, of which gastrointestinal bleeding, intestinal perforation, and typhoid encephalopathy are the most important. Gastrointestinal bleeding is the most common symptom and it occurs in up to 10% of patients. It results from the erosion of a necrotic Peyer's patch through the wall of an enteric vessel. In the majority of cases, the bleeding is slight and resolves without the need for blood transfusion. In 2% of cases, however, bleeding is clinically significant and can be rapidly fatal if a large vessel is involved. Intestinal (usually ileal) perforation is the most serious complication of the disease and it occurs in 1 to 3% of hospitalized patients.

Colonoscopic manifestations of typhoid fever with lower gastrointestinal bleeding.Colonoscopic manifestations of typhoid fever with lower gastrointestinal bleeding.

 

Typhoid Ulcer

Video Endoscopic Sequence 3 of 12.

Appendix Hole Area

Intestinal bleeding in typhoid fever usually occurs from the ulcers in the ileum or the proximal colon, and the most common colonoscopic manifestations are multiple variable-sized punched-out ulcerations. The shape of the ulcers is usually ovoid with the longest diameter parallel to the long axis of the gut, so that stricture formation does not occur after healing. The edges are soft, swollen and irregular, but not undermined. The floor is usually smooth and is formed by the muscular coat. Near the ileocecal valve, where perforation occurs more commonly, ulcers become deeper than elsewhere. Although uncommon, sporadic cases of typhoid fever still occur.

 

Typhoid Ulcers

Video Endoscopic Sequence 4 of 12.

Terminal Ileum Typhoid Ulcers

Involvement of the small intestine is nearly universal. Hemorrhage and intestinal perforation are the two major complications of small intestinal typhoid infection. Therapy for hemorrhaged small intestine in typhoid fever is initially supportive, consisting of blood transfusions and administration of antibiotics. In massive or recurrent hemorrhage, consideration is given to surgical resection of the involved small-intestinal segment. Operative management of the complications of small intestinal typhoid infection has a high associated mortality rate. Here we report a case of typhoid ileitis with massive hemorrhage from diffuse punched-out ulcerations and erosions in the terminal ileum successfully treated by surgical excision of the diseased part.

 

 

 

 

 


Terminal Ileum Typhoid Ulcer

Video Endoscopic Sequence 5 of 12.

Terminal Ileum Typhoid Ulcer

 

 

Terminal Ileum Typhoid Ulcer

Video Endoscopic Sequence 6 of 12.

Terminal Ileum Typhoid Ulcer

 

Terminal Ileum Typhoid Ulcer

Video Endoscopic Sequence 7 of 12.

Terminal Ileum Typhoid Ulcer

 

Terminal Ileum Typhoid Ulcers

Video Endoscopic Sequence 8 of 12.

Terminal Ileum Typhoid Ulcers

 

 

Typhoid Ulcer

Video Endoscopic Sequence 9 of 12.

Terminal Ileum Typhoid Ulcers

We proceed to obtain their respective biopias which were negative for granulomatous disease or lymphoma.

Typhoid Ulcer

Video Endoscopic Sequence 10 of 12.

Terminal Ileum Typhoid Ulcers

One of the observed ulcers with the traction exerted by the biopsy forceps.

 

Typhoid Ulcer

Video Endoscopic Sequence 11 of 12.

Typhoid ileo-colitis Ulcers

 

Poliposis juvenil

Video Endoscopic Sequence 12 of 12.

It is observed one ulcer of the cecum with abundant blood remaining.

Typhoid Fever.

Colonoscopy in Typhoid Fever

As a complication of typhoid fever, developed massive fresh bleeding per rectum. During colonoscopy, was discovered to have multiple bleeding ulcers lesion in the terminal ileum and ileocecal region.

Intestinal hemorrhage due to a typhoid fever.
The ileocecal valve and the terminal ileum are seen in the video clip. The most frequent and severe complication is intestinal perforation with peritonitis

There are several tiny and bleeding ulcers.
Invasion of Peyer patches occurs during either the primary intestinal infection or secondary bacteremia, and further seeding occurs through infected bile.

The Peyer patches become hyperplastic with infiltration of chronically inflamed cells, which may lead to necrosis of the superficial layer and ulcer formation, with potential hemorrhage from blood vessel erosion or peritonitis from transmural perforation.

Typhoid fever and paratyphoid fever is a systemic infection caused by Salmonella enterica, including S. enterica serotype Typhi (S. typhi) and serotype Paratyphi (S. paratyphi). Enteric fever is a faecal-oral transmissible disease and thus occurs in an environment with overcrowding, poor sanitation and untreated water.

Intestinal bleeding in typhoid fever usually occurs from the ulcers in the ileum or the proximal colon, and the most common colonoscopic manifestations are multiple variable-sized punched-out ulcerations. The shape of the ulcers is usually ovoid with the longest diameter parallel to the long axis of the gut, so that stricture formation does not occur after healing. The edges are soft, swollen and irregular, but not undermined. The floor is usually smooth and is formed by the muscular coat. Near the ileocecal valve, where perforation occurs more commonly, ulcers become deeper than elsewhere. Although uncommon, sporadic cases of typhoid fever still occur.

 

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