Gall Bladder Perforation by Typhoid Complication

Surgical complications of typhoid fever are uncommon and usually when it occurs, it commonly involves gut than the gallbladder. We present a case report of 20years old gentleman who presented with ten days duration of fever and one day history of sudden severe generalized pain abdomen. Patient was evaluated and investigated and undergone laparotomy in the line of peritonitis. Operative finding was gallbladder perforation and he underwent cholecystectomy. Other investigations were supportive of typhoid fever. Patient improved and was discharged after seven days.


CASE REPORT
We report a case of 20 year male who with history of fever for 10 days.Fever was high grade, continuous without chills and rigor.Initially he had mild to moderate abdominal discomfort but one day prior to admission he developed severe generalized pain abdomen which was exacerbated by movements suggesting peritonism.Pain was associated with multiple episodes of vomiting.He denied any history of drug abuse, alcoholism, and jaundice.There was no history suggestive of recurrent biliary colic or chronic cholecystitis in the past.On examination, patient was very toxic looking with tachycardia, tachypnea and was febrile.Blood pressure was maintained.Abdomen was distended, rigid with tenderness and rebound tenderness all over the abdomen.Bowel sound was absent.Investigation reveled leucocytosis.X Ray chest couldn't reveal gas under the dome of diaphragm to support bowel perforation as a complication of typhoid fever.USG abdomen revealed gross fl uid collection in the peritoneal cavity with mild splenomegaly.On the background of history, examination fi nding and USG fi nding, provisional diagnosis of typhoid fever induced small bowel perforation was made.Patient was resuscitated and planned for laparotomy after necessary preoperative preparation.
Patient underwent midline laparotomy.On opening the abdomen almost around 2 liters of clear bilious fl uid was sucked out.Full evaluation of the bowel loops and other parts of the gastrointestinal tract was done to fi nd out the site of perforation.While evaluating the duodenum, we could see grossly infl amed gallbladder with a small perforation of around 0.5cmX 0.5cm perforation near the fundus.(Figure 1, 2).After thorough evaluation of the peritoneal cavity, it was confi rmed that the primary pathology leading to peritonitis was gallbladder perforation.
Cholecystectomy was performed.Postoperative period was uneventful.Patient received complete course of Antibiotics.In the mean time reports of Widal test was available which was strongly positive for type O and S tyhi H.But blood and bile couldn't grow any organism in culture.Patient was discharged on tenth postoperative day.

DISCUSSION
Perforation of gallbladder was fi rst noticed by J Duncan of royal Infi rmary Edinburgh (quoted Gonsalves in 1979) about 135 years ago. 4Perforation occurs in the presence of gallstone disease with incidence varying 5-12%.Typhoid fever is also occasionally known to cause gallbladder perforation in the absence gallstone disease. 5phoid cholecystitis usually present in the fi rst week of illness 2 .Clinical features suggestive of gallbladder perforation are nonspecifi c.Abdominal paracentesis may reveal bile stained ascetic fl uid. 6X ray Chest may not show gas under the diaphragm, like in our case and hence they are not always helpful.In around 70% case Ultrasound may detect collapsed gallbladder and a perforation or defect in the gallbladder wall.It can Show free fl uid or collection close to the gallbladder wall. 7high index of suspicion is needed to diagnose the condition.Surgical options include cholecystectomy or cholecystostomy. 2 However cholecystectomy may be desirable to prevent the carrier state of typhoid fever. 8Perforation of gallbladder usually occurs due to infl ammatory reaction and weakness of the wall in the course of disease. 8Histopathological examination of cholecystectomy specimens shows infl ammatory changes in the gallbladder that were also seen in our case.
Gallbladder perforation due to typhoid fever is a well known entity but an unusual complication.Patient present with sudden onset of pain abdomen in the background history of fever usually of one to two weeks duration.Clinically it is diffi cult to predict the diagnosis as gut perforation is usually thought when patient present with such features.It is evident only when abdomen is explored.Usually cholecystectomy is indicated to prevent the carrier state and outcome is excellent most of the time.