Neutropenic colitis, Typhlitis
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Neutropenic colitis, also known as typhlitis, is characterized by ileocolonic inflammation in immunosuppressed patients with neutropenia, fever, and abdominal pain. It is most commonly seen in patients with hematologic malignancies or following chemotherapy and is caused by bacterial translocation during neutropenia. Clinical presentation includes gastrointestinal symptoms like abdominal pain in addition to fever. Diagnosis involves imaging showing bowel wall thickening as well as ruling out other causes. Management is usually conservative involving antibiotics, bowel rest, and correction of neutropenia, though surgery may be needed for complications like perforation.
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Neutropenic colitis, Typhlitis
- 1. Neutropenic colitis Interesting case 22/8/18
- 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.
- 8. Pathogenesis Chemotherapeuticagents • methotrexate (n=5) • vincristine (n=2) • Cyclophosphamide (n=2) • Cytarabine (n=2) • Daunorubicin (n=1) • Cyclosporine (n=1) • Fludarabine (n=1) and/or doxorubicin (n=1). TahaSachaketal. AJSP2015
- 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).
- 14. Diagnosis MullasseryD et al. PediatrSurg2009 DifferentialDiagnosis • pseudomembranous colitis • inflammatorybowel disease • Appendicitis • ischemic colitis • other infectious colitis • GVHD
- 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)
- 18. Management FabioG Rodriguesetal. World journalof gastroenterology2017 Mx concepts Aggressive resuscitation Bowel rest ? G-CSF Board spectrum Antibiotics Surgery • Profound neutropenia (absolute neutrophil <100/mL) • Uncontrolled primary disease • Pneumonia • Hypotension • Multi-organ dysfunction • Invasive fungal infection
- 19. Management Modified from Cloutieretal Mx concepts Aggressive resuscitation Bowel rest ? G-CSF Board spectrum Antibiotics Surgery
- 20. Management FabioG Rodriguesetal. World journalof gastroenterology2017 Mx concepts Aggressive resuscitation Bowel rest ? G-CSF Board spectrum Antibiotics Surgery • Intraperitoneal bowel perforation • Uncontrolled bleeding • Development of other surgical conditions • Primary anastomosis is not recommended.