typhlitis; necrotizing/neutropenic enterocolitis; necrotizing enteropathy; ileocecal syndrome; cecitis
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Introduction
Life-threatening right-sided necrotizing enterocolitis[3].
Epidemiology
- immunosuppressed hosts
- generally occurs in neutropenic patients after cytotoxic chemotherapy
- may be more common among children than adults
- much more common in patients with acute leukemia (AML or ALL)
- 46% of patients with childhood leukemia
- also occurs in patients with lymphoma
Pathology
- incompletely understood
- mucosal injury by cytotoxic drugs
- neutropenia
- impaired host defense to invasion by microorganisms
- bowel wall thickening
- mucosal ulceration or loss of mucosa
- intramural edema
- hemorrhage
- necrosis
Clinical manifestations
- fever
- right lower quadrant abdominal tenderness, with or without rebound tenderness
- nausea/vomiting, diarrhea (often bloody) is common
- peritoneal signs & shock suggests bowel perforation
Laboratory
- blood cultures may be positive for aerobic gram-negative & anaerobic bacteria; fungemia also common
- complete blood count (CBC) confirms neutropenia
- stool culture
- Clostridium difficile toxin
Diagnostic procedures
- colonoscopy relatively contraindicated with neutropenia
Radiology
- 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]
- plain films of the abdomen may suggest a right lower quadrant mass
- barium enema contraindicated in patient with potentially necrotic bowel (may cause bowel perforation)
Complications
- bowel ischemia
- bowel perforation
- mortality rates of ~40-50%
Differential diagnosis
Management
- broad spectrum antibiotics (including gram-negative coverage for bowel flora)
- granulocyte colony-stimulating factor (G-CSF) may be useful in patients with neutropenia
- surgery is sometimes attempted to avoid perforation from ischemia
- most cases resolve with medical management alone
- mortality 40-50%[3] due to bowel necrosis, bowel perforation, sepsis
- recurrence is rare
More general terms
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
- ↑ 3.0 3.1 3.2 UpToDate Online 11.2 2003 http://www.uptodate.com
- ↑ eMedicine: Neutropenic Enterocolitis http://www.emedicine.com/med/TOPIC2658.HTM
- ↑ 5.0 5.1 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: https://www.ncbi.nlm.nih.gov/pubmed/16836946 Review.