A 9-year-old boy was brought to Sarvodaya’s emergency department in a critically ill condition after experiencing high-grade fever for nearly three weeks.
By the time he reached the Sarvodaya Hospital, Sec 8, Faridabad, he was weak, dehydrated and drowsy, with a tense abdomen and signs of shock. His blood investigations suggested enteric fever (typhoid), while an abdominal X-ray revealed gas beneath the diaphragm (muscle that sits under the lungs and helps to breathe), raising strong suspicion of an intestinal perforation (hole in the intestine).
He was earlier diagnosed with typhoid but care was somehow delayed or neglected.
At Sarvodaya, the investigation reports clearly showed the infection had spread to the intestines, resulting in intestinal perforation and contamination of the abdominal cavity. And so, immediate life-saving emergency surgery was planned, led by Dr Shweta K. Sharma, Senior Consultant of Paediatric Surgery.
During the first surgery, the affected portion of the intestine was removed, the bowel loops (a section of your intestine that is holding extra gas, fluid, or food because it is blocked or slow )were carefully separated, and the abdominal cavity was thoroughly cleaned. As the child was critically ill, in shock, and the surrounding intestine was inflamed and unhealthy, a temporary stoma (opening through the abdomen) was created to divert the stool and allow the bowel to heal safely rather than attempting immediate reconnection.
After approximately two months, once the child had fully recovered, a second-stage surgery was performed to close the temporary opening and restore normal intestinal continuity. The child recovered well after the procedure and was able to resume a normal diet within a few days.
Enteric fever, commonly known as typhoid fever, is an infection caused by Salmonella Typhi. In most cases, when diagnosed appropriately and treated under medical supervision, it can be managed with antibiotics and supportive care.
However, prolonged, inadequately treated or untreated enteric fever can sometimes lead to serious complications involving the intestine.
In this child, the prolonged illness had resulted in inflammation and damage to the intestine. Eventually, a portion of the ileum (the final and longest section of the small intestine ) developed ischaemic changes (happens when a part of your body gets less blood flow and oxygen than it needs ) and perforation (hole).
When an intestinal perforation occurs, intestinal contents can leak into the abdominal cavity. This can result in severe infection, abdominal sepsis and shock, making it a potentially life-threatening emergency.
The child presented with:
The medical team immediately began aggressive resuscitation and stabilisation. Because his blood pressure was dangerously low, support was required to maintain circulation and prepare him for emergency surgery.
Blood products were also arranged as part of the preoperative preparation.
An abdominal X-ray showed free gas under the diaphragm, a finding suggestive of gastrointestinal perforation.
At this point, delaying surgery could have further increased the risk to the child's life.
The child was taken urgently for abdominal exploration.
During surgery, the paediatric surgical team found:
The intestinal loops were severely stuck to one another. Therefore, the surgeons performed careful adhesiolysis, separating the bowel loops while taking care to avoid creating additional perforations.
(Adhesiolysis is a surgical procedure used to cut, break apart, and remove abnormal bands of scar tissue—called adhesions—that make internal organs stick together).
The abdominal cavity was thoroughly cleaned with peritoneal lavage to remove infected and contaminated fluid.
(Peritoneal Lavage is a medical procedure where fluid is infused into the abdominal cavity and then withdrawn to check for internal bleeding or infection, or to wash out the area during surgery).
The unhealthy, perforated portion of the intestine was then removed.
An ileostomy is a surgical operation that creates an opening in the belly wall to route waste out of the body from the small intestine instead of the colon.
One of the most important decisions during the first surgery was to divert the intestine through a temporary loop ileostomy rather than immediately reconnecting the bowel inside the abdomen.
This was not simply a matter of convenience. It was a decision made in the child's best interest given the severity of his condition.
At the time of surgery, the child had:
In such circumstances, immediately joining the affected intestinal ends may carry a higher risk of leakage because the tissues may be severely inflamed and infected.
A temporary ileostomy allows intestinal contents to exit through an opening on the abdominal wall, giving the repaired and recovering intestine time to heal.
The priority during the first operation was to control the infection, remove the diseased bowel and save the child's life.
Attempting definitive intestinal reconstruction in the same setting could have placed additional stress on an already critically ill child and unhealthy bowel.
Following surgery, the child received appropriate antibiotic treatment and intensive postoperative monitoring.
His condition gradually improved.
He recovered well after the emergency procedure; his oral intake was gradually resumed, and his family was taught appropriate stoma care. He was discharged once he was clinically stable and able to continue recovery at home.
The ileostomy, however, was always intended to be temporary.
The next step was to allow the child's body to recover completely before undertaking definitive intestinal restoration.
After approximately two months, once the child had recovered from the severe infection and was clinically fit for another procedure, he underwent ileostomy closure.
During this definitive surgery, the diverted intestinal segment was restored to its normal pathway and the abdominal wall opening was closed.
The child recovered well after the second procedure and was discharged within a week.
This completed the planned two-stage surgical treatment.
Typhoid is generally a medically manageable infection when diagnosed and appropriately treated.
The serious complication in this case highlights an important distinction: the infection itself does not automatically mean that surgery will be required.
Surgery becomes necessary when complications such as intestinal perforation, severe abdominal contamination or other surgical emergencies develop.
If a child with enteric fever develops signs suggesting intestinal involvement and the complication is recognised early, timely medical and surgical assessment may help prevent progression to a life-threatening emergency.
A prolonged or high-grade fever in a child should not be casually dismissed, particularly when it does not improve as expected.
Parents should seek medical evaluation if fever is accompanied by:
Children with intestinal emergencies require careful assessment because their physiological response to severe infection and their anatomical requirements differ from those of adults.
In this case, the paediatric surgical team had to make rapid decisions while the child was in shock.
The treatment required coordination between:
The first operation was focused on saving the child's life and controlling the source of infection. The second operation was performed after recovery to restore normal intestinal continuity.
Typhoid and other causes of prolonged high-grade fever should not be neglected. Early diagnosis, appropriate treatment and timely specialist care can help prevent a treatable infection from progressing into a life-threatening surgical emergency.
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