After finishing a C-Section during one of my first call nights here, the pediatrician on call asked me to see a young boy she had admitted with a four day history of abdominal pain. He had significant pain, most localized to the right lower abdomen, and a fever. She had started antibiotics and was asking about my opinion about his need for surgical intervention.
These kids are stoic and hard to read. Many don’t know French and I don’t know if they understand my simple inquires about their pain. This boy was silent and still but grimaced and grabbed my arm when I palpated his abdomen. Here in Togo the most likely cause of severe abdominal pain and fever in children is typhoid fever caused by a Salmonella bacteria from contaminated water. This infection predominantly affects the last part of the small intestine before it joins the colon. Appendicitis is always another possibility for children with these symptoms. I didn’t know which problem we were dealing with and obviously couldn’t just check a CT Scan of his abdomen to find out. We decided that an overnight trial of powerful antibiotics was a reasonable first step.
The following morning he was worse and surgery was clearly necessary. We encountered a lower abdomen full of pus and 5 holes in his small intestine. Salmonella typhi creates abscesses in the wall of small intestine that then open and create full thickness holes that contaminate the entire abdomen with bowel contents.
The surgical options included trying to repair all the holes or removing the severely diseased segment of intestine that contains them. Because these kids are often not well nourished at baseline and present here in an advanced stage of the disease - they don't always heal well. There is a significant risk of bowel repairs breaking down and leaking within days of the original operation - recreating the infected abdomen scenario. However, I thought that the risks of him not healing an intestinal anastamosis or not surviving in his village with an ostomy (either one or the other would be required if an intestinal resection was done) were higher.
I think hard about these sorts of decision - not really knowing the “right” answer. I decided to do the best repair of each hole that I could, closing them in layers and trying to not narrow his intestines too much or cause an obstruction in this process.
Thankfully, he improved steadily with fevers resolving, pain decreasing and the output from the drain I had left in his abdomen showing no signs of subsequent leak. By the fifth day after his operation he was eating again, tolerating oral medications and ready for discharge. He was still very weak and wore a consistently blank expression on his face, but I felt he was safe in the care of his mom.
I was so happy to seem him walk into clinic like this- looking much more bright eyed and happy and without signs of infection!
We see many people who we can’t help from a medical standpoint, often times it is hard to prove the diagnosis and we see death occur all too often. These kids who come in sick and then are restored back to health are special. We thank God for his mercy on them. We tuck them away in our memory, learn from them and keep trying when the next patient like them comes in.
