Discussion
Gangrenous gall bladder following S. Typhi or in association with S
Typhi is a rare occurrence in children. Also rare is the occurrence of a
non perforative peritonitis. Complicated typhoid fever is seen in about
10 % to 15% of children mainly during the second and third week of
illness[3]. Ileal perforation is the commonest complication of
typhoid managed surgically[4]. Gallbladder infections are fairly
common with Salmonellae being isolated from gallbladder of either
chronic or acute disease states[5]. However the diagnosis becomes
apparent only when features of acalculous cholecystitis or gallbladder
perforation develop in acute infections. [5].
Diagnosis of gall bladder disease in typhoid patients still remains
elusive even in endemic areas leading to delays in patient
management[6].Gallbladder disease was not suspected in this patient
and was initially booked for theatre to explore the cause of the
peritonitis. And a chance diagnosis of gallbladder gangrene and empyema
made at laparotomy. An ultrasound scan would have enabled diagnosis.
Sonographic findings of thickened gall bladder wall occurring with
thickened bowel wall especially ileum and caecum and multiple mesenteric
nodes is diagnostic of typhoid fever in endemic areas[7].
Salmonellae reach the gallbladder through the blood stream and have been
shown to have a tropism for the vesicular gallbladder wall.[5].In
acute typhoid infections, colonisations of the gall bladder is rarely
diagnosed but becomes apparent when features of acalculous cholecystitis
develop.
The gallbladder acts as a unique replication niche for salmonellae which
explains the high concentration of bacteria in infected gallbladders.
Salmonella is known to undergo both extracellular replication in bile as
well as intracellular replication in the epithelial cells of the gall
bladder wall. This causes sloughing of infected cells, inflammation and
tissue damage.[5] Intense inflammation of the gall bladder, coupled
with infection with a virulent organism like Salmonellae in an
immunocompromised individual lead to thrombosis of the cystic artery
with trans mural necrosis and perforation[8].
Neimers described three forms of gallbladder perforation, free
gallbladder perforation and generalized biliary peritonitis as type Ⅰ ,
pericholecystic abscess and localized peritonitis as sub-acute or type Ⅱ
, and cholecystoenteric fistula as type Ⅲ [9]. Gall bladder
perforations at the fundus are more likely to end up with a type I gall
bladder perforation whereas type II is associated with walling off of
the site of perforation by omentum or intestines often when the disease
is not limited to the fundus which our patient was afflicted
with[10].
The patient had matted inflamed and oedematous bowel with free pus in
the abdomen which was thought to either be due to a sealed perforation
since she had been on antibiotics.[11]though it could have also been
due to leakage of the pericholecystic abscess, there was no evidence of
this at laparotomy. Previous reports have shown that complicated
acalculous cholecystitis can occur in concordance with bowel
complications though this was not the case in this patient.[12]
Indications for surgery/cholecystectomy in children with acute
acalculous cholecystitis are complications like perforation, empyema and
gangrene commonly seen in patients with systemic bacterial
infections.[13]this was the treatment of choice in the patient who
underwent a subtotal cholecystectomy. This procedure with non-closure of
the cystic duct is associated with bile leak in up to 42 % of the
patients. [14]. Since there was no distal blockage of the
bile duct, conservative management was sufficient in managing the
patient.
In conclusion, increased suspicion especially in populations at risk by
attending physicians will enable use of available diagnostic tools like
ultrasound scan for early diagnosis and better patient management.
Conflict of Interest : The authors declare that they have no
conflicts of interest.
Informed Consent: Informed consent was obtained.
Funding : No funding was received for this study.