Online Submissions: http://www.wjgnet.

com/1007-9327office World J Gastroenterol 2010 September 7; 16(33): 4164-4168

wjg@wjgnet.com ISSN 1007-9327 (print)
doi:10.3748/wjg.v16.i33.4164 © 2010 Baishideng. All rights reserved.

BRIEF ARTICLE

Outcome of surgical treatment of intestinal perforation in

typhoid fever

Aziz Sümer, Özgür Kemik, Ahmet Cumhur Dülger, Aydemir Olmez, Ismail Hasirci, Erol Kişli, Vedat Bayrak,
Gulay Bulut, Çetin Kotan

Aziz Sümer, Özgür Kemik, Aydemir Olmez, Ismail Hasirci, segmental resection and end ileostomy with mucous
Erol Kişli, Vedat Bayrak, Çetin Kotan, Department of Gen- fistula operation. Postoperative morbidity was seen in
eral Surgery, Medical Faculty, University of Yüzüncü Yıl, Van, 5 cases and mortality was found in one case.
6500, Turkey
Ahmet Cumhur Dülger, Department of Gastroenterology, Medi- CONCLUSION: Intestinal perforation resulting from
cal Faculty, University of Yüzüncü Yıl, Van, 6500, Turkey
Salmonella typhi is an important health problem in East-
Gulay Bulut, Department of Pathology, Medical Faculty, Uni-
versity of Yüzüncü Yıl, Van, 6500, Turkey ern and Southeastern Turkey. In management of this ill-
Author contributions: Sümer A collected and analyzed the data ness, early and appropriate surgical intervention is vital.
and wrote the paper; Kemik Ö, Kişli E, Dülger AC, Bayrak V
and Kotan Ç contributed to the discussion; Kişli E, Bayrak V and © 2010 Baishideng. All rights reserved.
Kotan Ç performed the surgical operations; Bulut G performed
the pathological evaluation; Olmez A and Hasirci I collected the Key words: Intestinal perforation; Typhoid fever; Treat-
data. ment
Correspondence to: Aziz Sümer, MD, Assistant Professor,
Department of General Surgery, Medical Faculty, University of Peer reviewer: Radha K Dhiman, Associate Professor, Depart-
Yüzüncü Yıl, Van, 6500, Turkey. azizsumer2002@yahoo.com ment of Hepatology, Postgraduate Institute of Medical Educa-
Telephone: +90-432-2251024 Fax: +90-432-2164705 tion and Research, Chandigarh 160012, India
Received: May 10, 2010 Revised: June 6, 2010
Accepted: June 13, 2010 Sümer A, Kemik Ö, Dülger AC, Olmez A, Hasirci I, Kişli E,
Published online: September 7, 2010 Bayrak V, Bulut G, Kotan Ç. Outcome of surgical treatment of
intestinal perforation in typhoid fever. World J Gastroenterol
2010; 16(33): 4164-4168 Available from: URL: http://www.
wjgnet.com/1007-9327/full/v16/i33/4164.htm DOI: http://
Abstract dx.doi.org/10.3748/wjg.v16.i33.4164
AIM: To represent our clinical experience in the treat-
ment of intestinal perforation arising from typhoid fever.

METHODS: The records of 22 surgically-treated pa- INTRODUCTION

tients with typhoid intestinal perforation were evalu-
Typhoid fever is a febrile disease caused by Salmonella typhi,
ated retrospectively.
a Gram-negative bacillus, which does not present as a sig-
RESULTS: There were 18 males and 4 females, mean nificant health issue in developed countries, but continues
age 37 years (range, 8-64 years). Presenting symp- to be an important problem in tropical regions[1,2]. It is
toms were fever, abdominal pain, diarrhea or constipa- generally transmitted by the fecal-oral route and may oc-
tion. Sixteen cases were subjected to segmental resec- casionally lead to an epidemic. Typhoid fever remains a
tion and end-to-end anastomosis, while 3 cases re- notable public health issue in regions having no adequate
ceived 2-layered primary repair following debridement, and proper infrastructure[3].
one case with multiple perforations received 2-layered Although intestinal hemorrhage is the most com-
primary repair and end ileostomy, one case received mon complication of typhoid fever, intestinal perforation
segmental resection and end-to-end anastomosis fol- continues to be the most frequent reason behind high
lowed by an end ileostomy, and one case received morbidity and mortality[2]. Generally, hemorrhage and

WJG|www.wjgnet.com 4164 September 7, 2010|Volume 16|Issue 33|

 Sümer A et al . Surgical treatment of TIP

perforation occur in the terminal ileum secondary to ne- Table 1 Preferred surgical methods
crosis of Peyer’s patches at 2-3 wk after the onset of the
disease[4,5]. Frequency of perforation varies between 0.8% Preferred surgical methods Patients
and 18%[3,6,7]. Mortality rates of typhoid intestinal perfora- (n = 22)

tion (TIP) cases are reported to be between 5% and 62%. Segmental resection + anastomosis 16
Perioperative mortality rates are noted to rise up to 80% in Jejunum 3
Ileum 12
patients who received surgery due to late perforations[2,6-9].
Cecum (right hemicholectomy) 1
Studies focusing on TIP in large series, are generally Debridement + 2-layered primary repair 3
reported from endemic regions[3]. In a study including 2-layered primary repair + end ileostomy 1
229 cases, Asefa[10] notes TIPs as one of the most im- Segmental resection + anastomosis followed by an end 1
portant causes underlying the acute abdomen. ileostomy
Segmental resection + end ileostomy with mucous fistula 1
While early surgical procedures are regarded as defin-
itive treatments along with preoperative resuscitation and
postoperative intensive care, the methods that should be
used in surgery are still contentious. intestinal perforation cases, whereas the remaining pa-
The aim of the present study is to retrospectively re- tients were operated on with the prediagnoses of peptic
view TIP cases and evaluate the outcomes of this compli- ulcer perforation, perforated appendicitis, and generalized
cation among patients treated in the Department of Gen- peritonitis. In all cases, laparotomy was performed by
eral Surgery, Faculty of Medicine, Yuzuncu Yil University midline incision. Six cases demonstrated multiple perfora-
of Van, which has provided healthcare services since 1994 tions, while 16 cases showed perforation on the antimes-
enteric side, appearing similar to a staple hole. One of the
to a wide region of Turkey encompassing many provinces
cases with multiple perforations had 7 perforation foci.
and districts.
The location of the perforations was the jejunum in 3
cases (located at an average distance of 63 cm from the
MATERIALS AND METHODS Treitz ligament), the ileum in 18 cases (located at an aver-
age distance of 50 cm from the ileocaecal valve), and the
The study included 22 cases admitted with an acute abdo-
cecum in one case. Based on the preference of operating
men profile who were diagnosed with TIP and treated in
surgeons and the extent of peritoneal contamination, 15
the Department of General Surgery between 1994 and
cases (68.2%) were subjected to segmental resection and
2010. By retrospectively reviewing the patient records, the
end-to-end anastomosis, while 3 cases (13.6%) received
cases were analyzed in terms of demographic, medical, 2-layered primary repair following debridement, one case
and surgical personal data. The cases were evaluated with (4.55%) with multiple perforations received 2-layered pri-
regard to age, gender, number of perforations, localization mary repair and end ileostomy, one case (4.55%) received
of the perforation, type of operation, and morbidity and segmental resection and end-to-end anastomosis, followed
mortality rates. With the exception of 3 patients who were by an end ileostomy, one case (4.55%) received right hemi-
admitted to the Department of Internal Diseases and cholectomy and end-to-end anastomosis, and one case
Department of Infectious Diseases and diagnosed with (4.55%) received segmental resection and end ileostomy
typhoid fever before being transferred to the Department with mucous fistula operation.
of Surgery upon development of acute abdomen, all cases Pezzer drains were inserted into both subhepatic and
initially presented to the Emergency Department because retrovesical spaces of 4 cases, while placing 2 Pezzer
of abdominal pain. The cases who were considered to be drains in the retrovesical space in one case, and one Pez-
prediagnosed with acute abdomen secondary to medical zer drain in the retrovesical spaces of 17 cases. The pre-
history and physical examination results, were subjected to ferred surgical methods are outlined in Table 1. In all the
erect abdominal plain film, posterior to anterior lung film, 19 patients who had no serological or bacteriological diag-
complete blood count, complete urinalysis, and biochemi- nosis, typhoid fever diagnosis was verified by isolation of
cal analysis including amylase. None of our patients, even Salmonella typhi serologically and/or from stool. The case
those who were reported to have intraabdominal free fluid who presented with a sepsis profile and was subjected to
by ultrasonography, received paracentesis. ileum resection and anastomosis treatment, died postop-
eratively at 10 h. Five cases, including a patient who re-
ceived debridement and primary repair before formation
RESULTS of an ileal fistula that closed spontaneously during the
There were 18 males (81.8%) and 4 females (18.2%), with postoperative period, and 4 patients who exhibited wound
an age range of 8-64 years (mean, 37 years). Common infection, developed morbidity.
symptoms were fever, abdominal pain, and vomiting.
Physical examination revealed generalized peritonitis in all Histopathologic results
cases. Each patient received urinary and nasogastric cath- Macroscopic view: In patients who received resection,
eters prior to the operation. Fluid/electrolyte imbalance there were ulcers in the jejunum, ileum, and cecum, which
was corrected and antibiotherapy was started. Three cases had a perforated appearance, extending parallel to the axis
transferred from the Departments of Internal Diseases of the intestines and displaying a length varying between 0.2
and Infectious Diseases were diagnosed and recorded as and 2 cm. Mesenteric lymphadenomegaly was determined.

WJG|www.wjgnet.com 4165 September 7, 2010|Volume 16|Issue 33|

 Sümer A et al . Surgical treatment of TIP

Those complications generally occur during the sec-

A
ond or third week of the disease[3-5]. While typhoid fever
often affects the terminal ileum, in rare cases the jejunum
and cecum may also be involved[9]. TIP in appendicitis
cases has been mentioned as a case report in the litera-
ture[12]. Typhoid fever is known to cause spontaneous
gall bladder perforation among cases with no cholelithia-
sis[1]. Cecal ulcers are smaller than the ones occurring in
the jejunum, and they seldom demonstrate perforation.
Generally, TIP occurs as a single perforation similar to a
stapler hole, and is localized on the antimesenteric side[9].
In the present study, perforations were localized in the
B jejunum in 3 patients, in the ileum in 18 patients, and in
the antimesenteric side of the caecum in one patient. The
length of the perforations localized in the jejunum and
ileum, varied between 0.5 and 2 cm, while the size of the
perforation in the cecum was found to be smaller, thereby
being consistent with the relevant literature.
The number and size of ulcers do not have any rela-
tionship with the severity of the symptoms. Characteris-
tically, those ulcers do not cause symptoms of peritoneal
irritation before being perforated, and the peritoneal re-
sponse following perforation is observed to be delayed.
Unlike other perforations, in cases with TIP, the omen-
tum does not migrate to the perforation site[9].
Figure 1 Histopathologic view of typhoid lesions. A: Typhoid nodule, there
are macrophages containing bacteria, red blood cells, and nuclear debris from
In the study of Ameh et al[13], fever and abdominal
small nodular aggregates in Peyer’s patches (HE stain, × 20 objective); B: Ty- pain were found to be the most common symptoms,
phoid ulceration (HE stain, × 5 objective). whereas guarding was observed to be the most com-
mon physical examination finding. All our 22 cases had
fever, abdominal pain and peritoneal irritation signs in
Microscopic view: The sections acquired from the ulcer-
the physical examination. However, none of our cases
ated areas showed loss of mucosal integrity, enclosure of
demonstrated a sign of synchronous intestinal hemor-
the muscular mucosa by the ulcers which also appeared to
rhage. Relative bradycardia is an important finding for
have destroyed the inner circular muscle layer, a predomi-
nance of macrophages beneath the mucosa and in the enteric fever and it is seen more commonly among adult
adjacent areas, and infiltrating mononuclear inflammatory and adolescent patients[14]. In this series, none of the
cells. The typhoid nodule (Figure 1A) had macrophages cases displayed that finding. In addition, among typhoid
containing bacteria, red blood cells, and nuclear debris fever cases, hepatosplenomegaly is known to be frequent,
from small nodular aggregates in Peyer’s patches. In ty- and while it is reported to be the most common physical
phoid ulceration (Figure 1B) macrophages, which are also finding in one study[4], we did not determine even a single
defined as typhoid cells, were observed to form clusters in splenomegaly case among our patients.
the mesenteric lymph ganglia. TIP is encountered rarely among people under the age
of 5 years and over the age of 50 years. More than 50%
of the cases are seen during the second and third decades
DISCUSSION of life. Its prevalence in men is 3 times higher than in
In the current study 22 surgically treated patients with TIP women[7,9]. Saxe et al[2] conducted a study of 112 cases with
were evaluated. The most common surgical intervention typhoid perforation and found the mean age was 20 years
was segmental resection with end-to-end anastomosis. (range, 3-75 years) and the male/female ratio was 1.73. In
Most fatal complications of typhoid fever are intesti- another 2 similar studies, the male/female ratio was found
nal hemorrhage and enteric perforation. Those complica- to be 2.5 and 4[15,16]. In the stuıdy of Atamanalp et al[7],
tions occur secondary to necrosis of Peyer’s patches[3,7,8]. mean age was found to be 36.3 years (range, 7-68 years).
Typhoid fever leads to hyperplasia in the reticuloendo- In the current study, mean age was 37 years (range, 8-64
thelial system, necrosis, and ulceration limited to Peyer’s years) and the male/female ratio was 4.5. Risk factors for
patches[1,9]. The frequency of TIP is reported to vary perforation among hospitalized patients were determined
between 0.8% and 39%, depending on the geographic to be short symptomatic period prior to presentation,
region[7-9]. Butler[11] reviewed 15 980 typhoid fever cases leukopenia, inadequate treatment, and being male[4]. Al-
from the world literature and found the frequency of though the exact underlying mechanism of TIP among
TIP to be 2.8%. In our country, the frequency of typhoid men is not yet known, spending longer time and consum-
complications is around 20%[3]. Hosoglu et al[4] reported ing more food outdoors may lead to more frequent con-
the frequency of TIP as 10.5%. tact with the bacillus[7].

WJG|www.wjgnet.com 4166 September 7, 2010|Volume 16|Issue 33|

 Sümer A et al . Surgical treatment of TIP

TIPs started to be treated surgically towards the end differences in reported mortality rates have revealed the
of the 1800s. As a result of understanding the pathogen- need to investigate the underlying reasons. Young age,
esis of typhoid fever and using more effective antibio- inadequate medical treatment, late presentation, number
therapies, early surgery has become the optimal treatment of perforations and sepsis are mentioned among the fac-
option for perforations[1]. However, the method to be tors influencing mortality[1]. Some authors claim that the
applied in surgical treatment of TIP cases, is still conten- number of perforations might affect prognosis[20,22]. On
tious. From a practical point of view, the perforation site the other hand, Rahman et al[17] and Atamanalp et al[7] de-
should be closed and the peritoneal cavity should be ir- termined no significant correlation between the number
rigated in the surgical treatment. In multiple perforations, of perforations, and prognosis and mortality. We found
segmental resection and anastomosis can be performed no study reporting a relationship between the localiza-
safely[2]. Rahman et al[17], found no correlation between the tion of perforation and prognosis in the literature. In
applied surgical procedure and the reduction in mortal- the present study, among our 22 cases, only one 62-year-
ity. In a majority of the cases, TIP affects the ileum and old patient with sepsis died in the postoperative period.
primary repair is appropriate. Shah et al[18] found the rates The low mortality rate in our study might be secondary
of complications and mortality in resection-anastomosis to factors such as early and appropriate surgical interven-
patients were lower than in other intervention groups. tion, effective perioperative resuscitation, postoperative
Therefore, they advocated resection-anastomosis as the intensive care procedures, safe anesthesia, and delivery of
ideal surgical method for typhoid enteric perforations. wide-spectrum antibiotics with low resistance.
Similarly, Athié et al[19] performed surgery on 352 The most common complication of TIP cases is
cases with typhoid ileal perforation, and found the rates wound infection, while the most serious is formation of
of mortality and morbidity in the resection-anastomosis a fecal fistula. Wound dehiscence, intestinal obstruction,
group were lower than in the primary closure group. intraabdominal abscess, empyema, bleeding diathesis, and
They recommended a 10 cm resection from the upper psychosis may occur[7]. In the present study, one case de-
and lower ends of the perforation and anastomosis (even veloped an ileal fistula which closed spontaneously in the
if there is only one perforation) in cases with a perfo- postoperative period and 4 cases developed wound infec-
rated ileum. However, Beniwal et al[20] suggested primary tion (5 complications in total).
closure as the first choice of treatment. Similarly, Shukla In conclusion, the treatment of TIP consists of ap-
et al[21], reported a reduction in mortality rate from 35% propriate early surgical intervention, effective resuscitation
to 10.8%, secondary to using a single-layer primary clo- in the preoperative period, postoperative care, and use of
sure method. Adesunkanmi et al[22], advocated the 2-layer proper antibiotics. Although primary closure is the most
closure technique as the most successful surgical method frequently recommended procedure, segmentary resection
regardless of the application of an omental patch. In the and end-to-end anastomosis may be reserved for patients
study of Saxe et al[2], which included 112 typhoid enteric with multiple perforations. Segmentary resection and end-
perforation cases, 77% of the cases received primary re- to-end anastomosis has low mortality and morbidity rates.
pair for single perforation, while 19% of the cases were Thus resection-anastomosis should be used as a surgical
subjected to segmental resection because of multiple treatment method for TIP. Ileostomy is associated with
perforations. Atamanalp et al[7] performed surgery on 82 high mortality and morbidity. However, it may be life-
patients with typhoid ileal perforation: primary repair af- saving in patients with severe abdominal contamination.
ter debridement in 32 cases, wedge resection and primary
closure in 9 cases, resection and anastomosis in 9 cases,
COMMENTS
COMMENTS
end ileostomy after resection in 28 cases, and exterioriza-
tion in 4 cases. In multiple perforation cases where short Background
bowel syndrome development is likely, primary repair is Typhoid fever is a febrile disease caused by Salmonella typhi and is an im-
recommended instead of resection[3,23]. Several authors portant problem in tropical regions. Progression of disease is associated most
commonly with hemorrhage and intestinal perforation.
suggest ileostomy in cases with delayed multiple perfora-
tion and diffuse peritoneal contamination[22,24,25]. Research frontiers
Typhoid perforation is an important complication of typhoid fever. It is seen
Recently, laparoscopic treatment methods have also rarely, but shows a high mortality and morbidity. The mainstay of treatment of
been employed in TIP cases. Ramachandran et al[26] re- typhoid intestinal perforation is surgery.
ported 6 successful laparoscopic primary closure cases. Innovations and breakthroughs
Sinha et al[27] treated 25 cases laparoscopically with a port- Recent reports have highlighted the importance of surgical treatment. Patho-
site infection rate of 8%. genesis of typhoid perforation indicates the need for more effective antibiotic
therapies and early surgery.
The mortality rate in TIP cases is reported to vary
between 5% and 60%[7,9,28]. Saxe[2] found a postoperative Applications
Although primary closure is the most frequently recommended procedure, this
mortality rate of 16%. In the studies of Ameh[13] and research opens the way for new surgical options such as segmentary resection
Meier et al[24], the mortality rates were 20% and 39%, re- and end-to-end anastomosis.
spectively. Atamanalp et al[7] determined a mortality rate Peer review
of 11%. Although, mortality rates have shown a decrease After reviewing the literature on surgical aspects, authors should recommend
lately, they are still at important levels. The significant the surgery of choice and should be included in conclusions.

WJG|www.wjgnet.com 4167 September 7, 2010|Volume 16|Issue 33|

 Sümer A et al . Surgical treatment of TIP

15 Onen A, Dokucu AI, Ciğdem MK, Oztürk H, Otçu S, Yüc-

REFERENCES esan S. Factors effecting morbidity in typhoid intestinal per-
1 Saxena V, Basu S, Sharma CL. Perforation of the gall blad- foration in children. Pediatr Surg Int 2002; 18: 696-700
der following typhoid fever-induced ileal perforation. Hong 16 Agbakwuru EA, Adesunkanmi AR, Fadiora SO, Olayinka
Kong Med J 2007; 13: 475-477 OS, Aderonmu AO, Ogundoyin OO. A review of typhoid
2 Saxe JM, Cropsey R. Is operative management effective in perforation in a rural African hospital. West Afr J Med 2003;
treatment of perforated typhoid? Am J Surg 2005; 189: 342-344 22: 22-25
3 Kotan C, Kosem M, Tuncer I, Kisli E, Sönmez R, Çıkman Ö, 17 Rahman GA, Abubakar AM, Johnson AW, Adeniran JO.
Söylemez Ö, Arslantürk H. Typhoid intestinal perforation: Typhoid ileal perforation in Nigerian children: an analysis of
Review of 11 cases. Kolon Rektum Hast Derg 2000; 11: 6-10 106 operative cases. Pediatr Surg Int 2001; 17: 628-630
4 Hosoglu S, Aldemir M, Akalin S, Geyik MF, Tacyildiz IH, 18 Shah AA, Wani KA, Wazir BS. The ideal treatment of the
Loeb M. Risk factors for enteric perforation in patients with typhoid enteric perforation - resection anastomosis. Int Surg
typhoid Fever. Am J Epidemiol 2004; 160: 46-50 1999; 84: 35-38
5 Dutta TK, Beeresha, Ghotekar LH. Atypical manifestations 19 Athié CG, Guízar CB, Alcántara AV, Alcaraz GH, Montalvo
of typhoid fever. J Postgrad Med 2001; 47: 248-251 EJ. Twenty-five years of experience in the surgical treatment
6 Pegues DA, Miller SI. Salmonella Species, Including Salmo- of perforation of the ileum caused by Salmonella typhi at the
nella Typhi. In: Mandell GL, Bennett JE, Dolin R, editors. General Hospital of Mexico City, Mexico. Surgery 1998; 123:
Mandell, Douglas, and Bennett's Principles and Practice of 632-636
Infectious Diseases. 7th ed. Philadelphia: Elsevier Churchill 20 Beniwal US, Jindal P, Sharma J, Jain S, Shyam G. Compara-
Livingstone, 2009: 2287-2903 tive study of postoperative procedures in typhoid perfora-
7 Atamanalp SS, Aydinli B, Ozturk G, Oren D, Basoglu M, tion. Indian J Surg 2003; 65: 172-177
Yildirgan MI. Typhoid intestinal perforations: twenty-six 21 Shukla VK, Sahoo SP, Chauhan VS, Pandey M, Gautam A.
year experience. World J Surg 2007; 31: 1883-1888 Enteric perforation--single-layer closure. Dig Dis Sci 2004; 49:
8 Mock CN, Amaral J, Visser LE. Improvement in survival 161-164
from typhoid ileal perforation. Results of 221 operative cases. 22 Adesunkanmi AR, Ajao OG. The prognostic factors in ty-
Ann Surg 1992; 215: 244-249 phoid ileal perforation: a prospective study of 50 patients. J
9 Eggleston FC, Santoshi B, Singh CM. Typhoid perforation of R Coll Surg Edinb 1997; 42: 395-399
the bowel. Experiences in 78 cases. Ann Surg 1979; 190: 31-35 23 Eustache JM, Kreis DJ Jr. Typhoid perforation of the intes-
10 Asefa Z. Pattern of acute abdomen in Yirgalem Hospital, tine. Arch Surg 1983; 118: 1269-1271
southern Ethiopia. Ethiop Med J 2000; 38: 227-235 24 Meier DE, Tarpley JL. Typhoid intestinal perforations in Ni-
11 Butler T, Knight J, Nath SK, Speelman P, Roy SK, Azad gerian children. World J Surg 1998; 22: 319-323
MA. Typhoid fever complicated by intestinal perforation: a 25 Gedik E, Girgin S, Taçyildiz IH, Akgün Y. Risk factors af-
persisting fatal disease requiring surgical management. Rev fecting morbidity in typhoid enteric perforation. Langenbecks
Infect Dis 1985; 7: 244-256 Arch Surg 2008; 393: 973-977
12 Golakai VK, Makunike R. Perforation of terminal ileum and 26 Ramachandran CS, Agarwal S, Dip DG, Arora V. Laparo-
appendix in typhoid enteritis: report of two cases. East Afr scopic surgical management of perforative peritonitis in
Med J 1997; 74: 796-799 enteric fever: a preliminary study. Surg Laparosc Endosc Per-
13 Ameh EA. Typhoid ileal perforation in children: a scourge in cutan Tech 2004; 14: 122-124
developing countries. Ann Trop Paediatr 1999; 19: 267-272 27 Sinha R, Sharma N, Joshi M. Laparoscopic repair of small
14 Katar S, Onur H, Yaramıs A, Ozbek MN, Ecer S. Enteric bowel perforation. JSLS 2005; 9: 399-402
fever in 19 children cases with positive hemocultures. Çocuk 28 Ekenze SO, Ikefuna AN. Typhoid intestinal perforation un-
Sağlığı ve Hastalıkları Dergisi 2006; 49: 19-23 der 5 years of age. Ann Trop Paediatr 2008; 28: 53-58

S- Editor Wang YR L- Editor Cant MR E- Editor Lin YP

WJG|www.wjgnet.com 4168 September 7, 2010|Volume 16|Issue 33|