2. Outline
• Case scenario
• Mini Topic
– Definition
– Pathogenesis
– Clinical presentation
– Diagnosis
– Management
• Take home message
3. A topic review :
Typhlitis,Neutropeniccolitis
ASD11N interesting case
4. Definition
• Typhlitis also known as necrotizing colitis,
neutropenic colitis, necrotizing enteropathy,
ileocecal syndrome, and cecitis
• A clinical syndrome of fever and right-lower-
quadrant (or generalized abdominal) tenderness
in an immunosuppressed host
• Characterizedas ileocolonic inflammation in patients
with neutropenia, fever, and abdominal pain. *
Harrison'sPrinciplesof InternalMedicine,20e * TahaSachaketal. AJSP2015
5. Definition
• More commonamong children than adults
• More commonamong patients with AML or ALL than
other types of cancer
• Initially described in leukemic pediatric patients
• It has also been reported in adults with hematologic
malignancies such as leukemia, lymphoma, multiple
myeloma, aplastic anemia, and myelodysplastic
syndromes, as well as other immunosuppressive
causes such as AIDS, therapy for solid tumors, and
organ transplant.*
Harrison'sPrinciplesof InternalMedicine,20e
* Fabio G Rodriguesetal. World journalofgastroenterology2017
7. Pathogen
• Bacterialtranslocation and bacteremia is also
frequently seen in these patients.
• Common causative organism :
Clostridium septicum, Escherichia coli, Kleibsiella
pneumoniae, Enterobactertaylorae,Morganella
morganii, Streptococcus viridans.
• 13 cases report : Bacillus cereus
• But alsoother Gram negative rods, gram-positive
cocci, enterococci, fungi, and virus
Fabio G Rodrigues et al. World journal of gastroenterology 2017
Cases reportinfectious disease 2018 Mar ; Denham JD et al.
9. Clinical presentation
Clinical clues n frequency
immunosuppression 20/20 100%
recent chemotherapy 17/18 94.4%
neutropenia 16/18 88.87%
Gastrointestinal symptoms 19/19 100%
abnormalimaging studies
of the cecum/right colon
11/14 78.57%
positive microbiological
studies
13/15 86.67%
Fever 9/15 60%
sepsis 8/16 50%
cecum/right colon was alwaysinvolved 17/17 100%
TahaSachaketal. AJSP2015
10. Diagnosis
Proposedcriteria
• Majorcriteria
Compatible histology
At least borderline neutropenia
Gastrointestinal symptoms
Immunosuppression
Recent chemotherapy
Exclusion of other treatable aetiologies
TahaSachaketal. AJSP2015
• Minorcriteria
Fever of >38๐C
Bowel wall thickening
of >4 mm over >30 mm
Positive microbiologic
studies
11. Diagnosis
• Fever
• Abdominalpain
MullasseryD et al. PediatrSurg2009
Signs and symptoms Investigations
• Neutropeniain CBC
• Thickening of bowel wall
in imaging
Triad= In a study that included 40 paediatric patients,
the clinical triad (fever, abdominal pain, and neutropenia)
was present in 31 patients (78%).
12. Diagnosis
Investigations : imaging
• Film plainabdomen : (limited Sn and Sp)
– dilated atonic cecum
– ascending colon filled with liquid or gas
– signs of intramural gas, and small bowel dilation
– pneumoperitoneum in perforated bowel
• Ultrasonicexamination
• CT abdomen : also help visualize other organs and a make differential diagnosis.
– bowel wall thickening, a dilated cecum or other colonic segment
– an inflammatory mass
– pericolonic inflammation
– pneumatosis intestinalis.
Prognostic : a mortality rate of 60% due to NE in patients with colonic wall
thickness of 10 mm compared to a mortality rate of 4.2% in patients with
mural thickness of < 10 mm, seen on ultrasound.
Cartonietal. J clinical onco2001
FabioG Rodriguesetal. World journalof gastroenterology2017
13. Diagnosis
Investigations : imaging
TahaSachaketal. AJSP2015
NE imaging findings. A andB, Computedtomographyimagesfrom 2 different patientswith NE; bothshow cecal
wall thickeninganddilation (brackets). C, Colonic dilatationon an abdominalradiograph;findingsare most
prominentin the cecum(bracket).
15. Management
• Initial reports of NE showed a preference for surgical
treatment as the high mortality associated with NE
led to a more aggressive treatment regimen.
• Conservative management consists of aggressive
fluid resuscitation, correction of electrolyte
imbalance, bowel rest, abdominal decompression,
and broad-spectrum antibiotics. Correction of
thrombocytopenia and clotting abnormalities can
require blood component transfusion.
FabioG Rodriguesetal. World journalof gastroenterology2017
16. Management
• Conservative management consists of
• aggressive fluid resuscitation
• correction of electrolyte imbalance
• bowel rest and abdominal decompression
• broad-spectrum antibiotics
• Correction of thrombocytopenia and clotting abnormalities can
require blood component transfusion.
• Initial reports of NE showed a preference for surgical
treatment as the high mortality associated with NE
led to a more aggressive treatment regimen.
FabioG Rodriguesetal. World journalof gastroenterology2017
17. Management
FabioG Rodriguesetal. World journalof gastroenterology2017
Mx
concepts
Aggressive
resuscitation
Bowel rest
? G-CSF
Board
spectrum
Antibiotics
Surgery
• Parenteral nutrition
• Possibility of
continuing GI tract in
selected patients.
• Glutamine as immuno-
nutrient (pending)