Fig. 15.5 Typhoid fever with perforation of the bowel of a Nigerian child. (A) Note the multiple loops of distended gas-filled small bowel on the supine view. (B) In the erect position multiple resting fluid levels are seen. The properitoneal fat lines are lost and several small bowel loops, especially in the right lower quadrant, appear fixed when the two projections are compared. There is free air below the liver margin on both views. (C) An erect chest film shows free air beneath the right hemidiaphragm. (Courtesy of Dr. Stanley Bohrer, Winston-Salem, North Carolina).


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Radiological Diagnosis

Radiographic examination is rarely indicated in uncomplicated typhoid and paratyphoid fevers because the pathological changes and clinical course of the diseases are well known. However, supine and erect or decubitus plain film examinations of the abdomen should be obtained whenever perforation of a typhoid ulcer is suspected.

In those typhoid patients who have a silent, distended abdomen without intestinal perforation the principal radiographic finding is a great accumulation of gas in distended loops of small intestine from a paralytic ileus. Fluid levels are uncommon. By contrast, peritonitis due to other diseases typically produces a generalized paralytic ileus with gaseous distention of the entire intestinal tract, with the colon being more distended than the small bowel. In patients with typhoid fever, the primary small bowel distention may be explained by small bowel paresis and functional obstruction prior to perforation; the inflamed distal ileum interferes with the onward propulsion of intestinal gas, which accumulates in the ileum and proximally, often in large amounts. Mechanical obstruction from kinking, edema and adhesions may further distend the small bowel after perforation; there is a paucity of gas in the colon, whereas in the usual ileus from peritonitis of different etiology there is often abundant colon gas.

The presence of free intraperitoneal gas in typhoid patients with perforation has been reported by some authors as being uncommon, but others have reported that up to 65% of their patients showed evidence of free gas, a finding duplicated in 6 of Bohrer's 12 Nigerian patients with classical typhoid perforation of the ileum. Five of these showed a marked amount of free gas, producing a double- contour sign of the bowel wall on supine films. In virtually all patients with perforation and clinical evidence of peritonitis, there are radiographic findings of peritonitis as well, consisting of loss of the properitoneal fat lines, free abdominal fluid and, in some patients, elevation of the diaphragm. Distention of the gas-filled bowel, especially the small intestine, is common, as is the presence of either resting or hoop-shaped fluid levels within the small bowel (Figs.15.5 & 15.6). There may be irregular narrowing and fixation of distal small bowel segments outlined by intraluminal gas.

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