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typhlitis; necrotizing/neutropenic enterocolitis; necrotizing enteropathy; ileocecal syndrome; cecitis
Life-threatening right-sided necrotizing enterocolitis [3].
Epidemiology:
1) immunosuppressed hosts
2) generally occurs in neutropenic patients after cytotoxic chemotherapy
3) may be more common among children than adults
4) much more common in patients with acute leukemia (AML or ALL)
5) 46% of patients with childhood leukemia
6) also occurs in patients with lymphoma
Pathology:
1) incompletely understood
2) mucosal injury by cytotoxic drugs
3) neutropenia
4) impaired host defense to invasion by microorganisms
5) bowel wall thickening
6) mucosal ulceration or loss of mucosa
7) intramural edema
8) hemorrhage
9) necrosis
Clinical manifestations:
1) fever
2) right lower quadrant abdominal tenderness, with or without rebound tenderness
3) nausea/vomiting, diarrhea (often bloody) is common
4) peritoneal signs & shock suggests bowel perforation
Laboratory:
1) blood cultures may be positive for aerobic gram-negative & anaerobic bacteria; fungemia also common
2) complete blood count (CBC) confirms neutropenia
3) stool culture
4) Clostridium difficile toxin
Special laboratory:
- colonoscopy relatively contraindicated with neutropenia
Radiology:
1) computed tomography (CT), ultrasonography or magnetic resonance imaging (MRI) showing a thickened cecal wall is diagnostic
- CT is imaging modality of choice
- fluid-filled, dilated cecum seen on CT
- thickening of the wall of the ascending colon [5]
2) plain films of the abdomen may suggest a right lower quadrant mass
3) barium enema contraindicated in patient with potentially necrotic bowel (may cause bowel perforation)
Complications:
1) bowel ischemia
2) bowel perforation
3) mortality rates of ~40-50%
Differential diagnosis:
1) pseudomembranous enterocolitis
2) ischemic colitis
3) Ogilvie's syndrome
Management:
1) broad spectrum antibiotics (including gram-negative coverage for bowel flora)
2) granulocyte colony-stimulating factor (G-CSF) may be useful in patients with neutropenia
3) surgery is sometimes attempted to avoid perforation from ischemia
4) most cases resolve with medical management alone
5) mortality 40-50% [3] due to bowel necrosis, bowel perforation, sepsis
6) recurrence is rare
General
enterocolitis
References
- Medical Knowledge Self Assessment Program (MKSAP) 11, American
College of Physicians, Philadelphia 1998
- Harrison's Principles of Internal Medicine, 14th ed.
Fauci et al (eds), McGraw-Hill Inc. NY, 1998, pg 539
- UpToDate Online 11.2 2003
http://www.uptodate.com
- eMedicine: Neutropenic Enterocolitis
http://www.emedicine.com/med/TOPIC2658.HTM
- NEJM Knowledge+ Gastroenterology
- Bremer CT, Monahan BP.
Necrotizing enterocolitis in neutropenia and chemotherapy: a clinical update and
old lessons relearned.
Curr Gastroenterol Rep. 2006 Aug;8(4):333-41.
PMID: 16836946 Review.