Three examples of causes of abdominal pain in immunosuppressed patients and their implications were discussed. Neutropenia enterocolitis can cause bowel necrosis and perforation leading to life-threatening sepsis, though outcomes have improved with prompt treatment. Cytomegalovirus enterocolitis in AIDS or transplant patients can cause ulceration and diarrhea but typically resolves with antiviral treatment. Bowel perforation is catastrophic and often fatal in immunosuppressed patients due to leakage of bowel contents and peritonitis, though early surgery improves chances of recovery.
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Abdominal pain in the Immunocompromised
1. Pain In Patients Who Are
Immunosuppressed And The
Implication On Treatment And
Outcomes
Examples: Neutropenia Enterocolitis,
CMV Enterocolitis, Bowel Perforation,
Acalculous Cholecystitis, Acute Graft
Rejection.
Presented by:
SUAME PRECIOUS MATTHEW
Thursday13/12/2018
2. OUTLINE
1. Introduction
• What is abdominal pain?
• Causes of immunosuppression
2. Who are the immunosuppresed?
3. Review of the anatomy of the abdomen
4. Causes of abdominal pain in the different regions of
the abdomen
5. Examples of immunosuppressed patient, cause of
their abdominal pain, implication on treatment and
outcomes
3. Introduction
What is pain?
• Pain is an unpleasant physical sensation caused by illness or injury.
What is abdominal pain?
• Abdominal pain is an unpleasant sensation felt in the abdomen (between the
chest and pelvic regions) caused by illness or injury.
Who are the immunosuppressed?
• Immunosuppression is a reduction of the activation or efficacy of the immune
system.
4. Causes of Immunosuppression
• Immunosuppression Resulting from Medications
Corticosteroids, cytotoxic drugs
• Immunosuppression Resulting from asplenia
• Immunosuppression after transplant (People who receive organ
transplants often need treatment with immunosuppressant
medications to reduce the risk of rejection.)
• Immunosuppression caused by infection (cytomegalovirus- CMV,
HIV
5. Pathophysiology
• Visceral pain
– Distention, inflammation or ischaemia
in hollow viscous & solid organs
– Localization depends on the embryologic
origin of the organ:
• Foregut to epigastrium
• Midgut to umbilicus
• Hindgut to the hypogastric region
• Parietal pain
– Localized to the dermatome above the site
of the stimulus.
• Referred pain
– produces symptoms, not signs e.g. tenderness
8. Causes Of Abdominal Pain In The Different Regions Of
The Abdomen
Generalized abdominal pain
• Perforation
• Abdominal aortic aneurysm
• Acute pancreatitis
• Diabetes mellitus
• Bilateral pleurisy
9. Central Abdominal Pain
• Early appendicitis
• Severe Bowel Occlusion
• Acute gastritis
• Acute pancreatitis
• Ruptured Abdominal Aortic Aneurysm
• Mesenteric thrombosis
16. Neutropenia enterocolitis (typhilitis /ceacitis)
• This is an inflammation of the cecum usually associated with
neutropenia(<1500 neutrophils/mL of blood)
• It occurs in immunosuppressed patients such as those undergoing
chemotherapy, patients with AIDS, Kidney transplant or the elderly.
Causes of pain in Neutropenia enterocolitis: Necrosis and perforation
of the bowel which causes peritonitis and sepsis.
Treatment outcomes: initially the mortality rate for typhilitis was
high as 50% mostly because it is frequently associated with bowel
perforation. Recent studies have demonstrated better outcomes with
prompt management, generally with resolution of symptoms with
neutrophil recovery without death.
17. Cytomegalovirus Enterocolitis
• Immunosuppresion- related CMV infection occurs mostly in
recipients of transplants and in patients with AIDS.
• It can be either primary infection or reactivation of a latent
infection.
• It is the most common opportunistic viral infection of AIDS.
• CMV enterocolitis leads to the development of necrosis and
ulceration and may be extensive, leading to the formation of
pseudomembrane and debilitating diarrhea.
• Although severe CMV colitis may need a colectomy. Most patients
recover from it. Irrespective of the presence or absence of
symptoms after infection, individuals who were once infected
becomes seropositive for life.
18. Bowel Perforation
• Perforation of the colon in the immunocompromised patient is a
catastrophic and usually fatal event. The immunocompromised
patient, like all patients, may suffer from the more common causes
of colonic perforation, including diverticulitis, chronic inflammatory
bowel disease, presence of a foreign body, and trauma.
• Perforated bowel leads to the leakage of bowel content into the
peritoneum, leading to peritonitis.
• The success of surgery to repair a perforation depends on the size of
the perforation and the length of time before intervention. The
chances of recovery improve with early diagnosis and treatment.
19. Acalculous Cholecystitis
• This is billary inflammation not caused by gallstones
• Acute acalculous cholecystitis is particularly seen in critically ill patients
resulting from bile stasis due to increased bile viscosity.
• It can also result from prolonged absence of oral feeding resulting in a decrease
or absence of cholecystokinin-induced gallbladder contraction and Gallbladder
wall ischemia
• Results in approximately 5-10% of all cases of acute cholecystitis and is usually
associated with more serious morbidity and higher mortality rates than
calculous cholecystitis.
• The cause of pain in acalculous cholecystitis is necrosis from inflammation
INFLAMMATION NECROSIS
• The diagnosis is often missed and the mortality rate is high
20. Acute Graft Rejection
• Allografts provoke a powerful immune response that results in
rapid graft rejection unless immunosuppressive therapy is given.
• Transplant antigens expressed by graft cells activate T cells and
stimulate them to proliferate in response to interleukin-2 (IL-2) and
other T-cell growth factors.
• The cellular effectors of graft rejection include cytotoxic CD8 T cells,
which recognize donor HLA class I antigens expressed by the graft
and cause target cell death by releasing lytic molecules such as
perforin and granzyme. Graft infiltrating CD4 T cells, which
recognize donor HLA class II antigens, mediate direct target cell
damage and are also able, by releasing cytokines such as interferon-
γ, to recruit and activate macrophages that act as non-specific
effector cells.
21. CONCLUSION
• Conditions presenting with abdominal pain abounds in the
immunosuppressed caused by infection, medication, asplenia, or
those having a transplant.
• The cause of this abdominal pain is due to an inflammatory
processes that results to necrosis and tissue death.
22. REFERENCES
• Bailey & Love’s Short practice of surgery 26th edition. Published by
Taylor & Francis Group, LLC. 2013
• Robbins Basic Pathology 10th edition. Kumar, Abbas, Aster. Published by Elsevier Inc. 2018
• en.wikipedia.org
