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Noon conference tb 7-31-18
- 1. © 2016 Virginia Mason Medical Center Question 1 According to the IDSA, at what ANC is neutropenia defined as? 1. <1500 2. <1000 3. <500 4. <100 1
- 2. Noon Conference Travis Baker DO PGY-1, Transitional Year 07/31/2018
- 3. © 2016 Virginia Mason Medical Center 3 Objectives Neutropenic Enterocolitis(Typhlitis) • Neutropenic Fever Definition • Pathophysiology • Risk Factors/Clinical Presentation • Diagnostic Tests • Management Options
- 4. © 2016 Virginia Mason Medical Center Neutropenic Fever Definition Infectious Disease Society Guidelines Fever: • Single Temperature greater/than equal to 38.3° C or 101° F. • Temperature of >38.0° C (100.4° F) for more than one hour Neutropenia: • True neutropenia is ANC <1500 cells/mm3 • IDSA defines it as <500 cells/mm3 Risk of Complications: • Low Risk: neutropenia expected for <7 days with no comorbidities • High: neutropenia expected for >7 days with comorbidities 4
- 5. © 2016 Virginia Mason Medical Center Pathophysiology 5 right lung nodules and infiltrates Mucosal injury by cytotoxic agents: • Taxanes, cytarabine, doxirubicin, 5-fluorouracil, cyclophosphamide, etoposide, alemtuzumab, and etc. • Inhibits cellular replication of the mucosa, leads to mucosal breakdown. Impaired host defenses: • Translocation of intestinal bacteria • -MC bacteria include gram negative bacilli, anaerobes, gram positive cocci • Causes necrosis of bowel layers • Cecum most commonly affected
- 6. © 2016 Virginia Mason Medical Center Risk Factors/ Clinical Presentation 6 Risk Factors: • Patient’s with Leukemia, Lymphoma, MM, or any other immunosuppression • Receiving chemotherapy within last 2 weeks. Clinical Presentation: • Fever • Abdominal Pain • Paralytic Ileus • Others: N/V, diarrhea, frank hematochezia, abdominal distention
- 7. © 2016 Virginia Mason Medical Center Question 2 Which imaging modality for NE has the lowest false negatives for diagnosis? 1) X-ray 2) C.T. 3) U.S. 4) Colonoscopy 7
- 8. © 2016 Virginia Mason Medical Center Diagnostic Tests • CBC w/ Diff • ANC!!!! • CMP • Blood cultures x2 • C. diff stool antigen test • Culture for enteric pathogens • CT A/P with and without contrast • Bowel thickening (100%) • Mesenteric stranding (52%) • Bowel dilation (38%) 8
- 9. © 2016 Virginia Mason Medical Center 9 Management Options • Supportive Therapy • Antibiotics • 14 days after neutropenia • Granulocyte Colony-Stimulating Factor • Usually w/ ANC <100 • Surgery?
- 10. © 2016 Virginia Mason Medical Center 10 Resources • Machado NO. Neutropenic enterocolitis: A continuing medical and surgical challenge. North American Journal of Medical Sciences. 2010;2(7):293-300. • Rodrigues FG, Dasilva G, Wexner SD. Neutropenic enterocolitis. World Journal of Gastroenterology. 2017;23(1):42-47. doi:10.3748/wjg.v23.i1.42. • Clinical Practice Guideline for the Use of Antimicrobial Agents in Neutropenic Patients with Cancer: 2010 Update by the Infectious Diseases Society of America • UptoDate: Neutropenic Enterocolitis • Medscape: Neutropenic Enterocolitis
- 11. © 2016 Virginia Mason Medical Center About Me 11
Editor's Notes
- ORAL TEMPERATURES! NO rectals! Low risk: these people are going through chemo for solid tumors High risk:Comorbidities include hypotension, PNA, abdominal pain, neuochanges, renal or liver dysfunction Or MASC (Multinational Association of Supportive Care in Cancer) <21 (lower is worst) used for assessing the risk of chemo neutropenic fever related complications. OR ANC <100 for for greater than 7 days.
- Cytotoxicity accounts for most of the causes but the mechanisms are still under investigation and exact pathways are still unknown. These are just most common factors. Agents most commonly associated with neutropenic enterocolitis include cytosine arabinoside (79%), etoposide (62%) and daunomycin (46%)
- MC leukemia is AML but other immunosuppression involves immunodeficiency syndromes or immunosuppression for treatment of solid malignancies and transplants. Abdominal pain, MC RLQ but can be anywhere and the median day is 17 days. Differential: including appendicitis and C. Diff colitis ●Graft-versus-host disease (GVHD) – GVHD can complicate allogeneic hematopoietic cell transplantation (HCT). Some patients with gastrointestinal tract GVHD will also have skin and/or liver involvement. GVHD typically occurs after engraftment, whereas neutropenic enterocolitis usually presents before engraftment. (See "Clinical manifestations, diagnosis, and grading of acute graft-versus-host disease".) ●Cytomegalovirus (CMV) colitis – Among patients with chemotherapy-induced neutropenia, CMV colitis is most likely to occur in HCT recipients. (See "Approach to the diagnosis of cytomegalovirus infection", section on 'Gastrointestinal disease'.) ●Norovirus infection – Although in immunocompetent hosts norovirus causes a self-limited gastroenteritis, in immunocompromised hosts it can cause a severe and/or prolonged diarrheal illness that can mimic neutropenic enterocolitis or GVHD or coexist with these entities. (See "Norovirus".) ●Ischemic colitis – Ischemic colitis occurs most commonly in older adult patients and involves the left side of the colon most often. (See "Colonic ischemia".) ●Ogilvie's syndrome (colonic pseudoobstruction) – Ogilvie's syndrome is a disorder characterized by gross dilatation of the cecum and right hemicolon (although occasionally extending to the rectum) in the absence of an anatomic lesion that obstructs the flow of intestinal contents. It is usually associated with an underlying disease, such as trauma, infection (eg, pneumonia, sepsis), myocardial infarction, congestive heart failure, surgery, or neurologic diseases. (See "Acute colonic pseudo-obstruction (Ogilvie's syndrome)", section on 'Clinical manifestations'.) ●Cholangitis – Acute cholangitis is a syndrome characterized by fever, jaundice, and abdominal pain that develops as a result of stasis and infection in the biliary tract. (See "Acute cholangitis: Clinical manifestations, diagnosis, and management", section on 'Clinical manifestations'.) ●Cholecystitis – Acute cholecystitis refers to a syndrome of right upper quadrant pain, fever, and leukocytosis associated with gallbladder inflammation that is usually related to gallstone disease.
- CT has the lowest false negative rate (15%) compared to Plain film (48%) and US abdomen (23%). Bowel thickening MC on CT. 100% of the time found. Can do xrays but more non-specific and common findings are air fluid level and pneumoperitoneum.
- Supportive Therapy- Bowel rest, NGT, IVF, poss transfusions in necessary, NO anticholinergics, or antidiarrheals Abx: for Pseudomonas, anaerobes, gam neg rods Pip –Tazo Cefepime/ Ceftazdime w/ Metronidazole Save imepenem and mertapenem for last resort ** If fever not resolving in 72 hours, may need to start antifungals for candida and aspergillus, voricanizole and amp. B GCSF- if everely ill, even though there is no good data to support this. Patient-related factors such as profound neutropenia (absolute neutrophil < 100/mL), uncontrolled primary disease, pneumonia, hypotension, multiorgan dysfunction, and invasive fungal infection are possible indications for the use of G-CSF in NE For bowel perf or severe bleeding after cytopenias have been tried to be resolved.