Enterocolitis neutropénica en el paciente oncológico pediátrico / Neutropenic enterocolitis in the pediatric cancer patient

Resumen La enterocolitis neutropénica (ECN) es una enfermedad heterogénea de foco digestivo, pero afectación sistémica, que corresponde a una condición clínica grave que amenaza la vida de pacientes inmunocomprometidos, particularmente oncológicos pediátricos. De patogenia aún poco definida y aunque de causa multifactorial, la ECN se asocia a los efectos citotóxicos de la quimioterapia empleada y se caracteriza por la triada clásica que incluye fiebre, neutropenia y dolor abdominal, donde la principal injuria se localiza en la mucosa intestinal, provocando su alteración como barrera y facilitando la invasión bacteriana intramural. La ECN constituye un reto diagnóstico para el equipo tratante, que requiere ser oportuno y contar con apoyo de un óptimo laboratorio general e imagenológico, para iniciar un completo manejo multidisciplinario en unidades y centros de alta complejidad. Se presenta una revisión actualizada del tema incorporando aspectos epidemiológicos, factores de riesgo, elementos de apoyo diagnóstico, consideraciones terapéuticas y medidas de prevención a fin de aportar en el conocimiento de esta patología, y reducir morbimortalidad en estos pacientes.

Abstract Neutropenic enterocolitis (NEC) is a heterogeneous disease of the gastrointestinal tract with systemic response, that corresponds to a severe and life-threatening clinical condition in immunocompromised patients, especially in childhood cancer. The pathologic features are poorly understood, although its multifactorial cause of NEC is well established and it is associated with the cytotoxic effects of the chemotherapy agents used and recognized by the classic triad of fever, neutropenia, and abdominal pain, secondary to gastrointestinal injuries that alters mucosal permeability and helps intramural bacterial invasion. NEC is truly a clinical challenge that requires an early diagnosis and a multidisciplinary approach including basic laboratory and imagological tests in high complexity centers. We present a current review, adding epidemiological aspects, risks factors, diagnostic support elements, therapeutic considerations, and preventive measures in order to provide knowledge of this disease and help to reduce morbidity and mortality associated with it.

Enterocolite Neutropênica em Paciente com Câncer de Mama em Uso de Quimioterapia Adjuvante: Relato de Caso / Neutropenic Enterocolitis in a Breast Cancer Patient using Adjuvant Chemotherapy: Case Report / Enterocolitis Neutropénica en Paciente con Cáncer de Mama que Usa Quimioterapia Adyuvante: Reporte de Caso

Introdução: A enterocolite neutropênica (EN) consiste em ulceração ou necrose da mucosa do ceco, íleo terminal e cólon ascendente, sendo uma condição clínica ocasionada como evento adverso de medicamentos, principalmente em esquemas quimioterápicos. Por ser uma condição com alto índice de mortalidade, o presente relato tem como objetivo contribuir significativamente para discussões que envolvem a EN e a participação da equipe multiprofissional no desfecho clínico. Relato do caso: Paciente do sexo masculino, 75 anos, com diagnóstico de câncer de mama, evoluindo com EN após tratamento com quimioterapia adjuvante. A presença de comorbidades e a idade foram os principais fatores complicadores do quadro de tiflite. Por ser uma toxicidade importante e que pode levar à piora do quadro clínico do paciente com câncer, abordar esse tema é fundamental para um diagnóstico mais rápido, com possibilidade de medidas preventivas. Conclusão: Sendo assim, em virtude do notório aumento dos casos de EN, aponta-se como perspectiva a qualificação da equipe de saúde para a inserção de profissionais ainda mais especializados, capazes de contribuir e identificar os sinais e sintomas relacionados com toxicidades hematológicas, resultado de tratamentos quimioterápicos.

Introduction: Neutropenic enterocolitis (NE) consists of ulceration or necrosis of the mucosa of the cecum, terminal ileum, and ascending colon, being a clinical condition caused by an adverse drug event, mainly in chemotherapy regimens. As it is a high mortality rate condition, this report aims to contribute significantly to discussions involving NE and the participation of the multidisciplinary team in the clinical outcome. Case report: This is a 75-year-old male patient diagnosed with Breast Cancer, who developed EN after treatment with adjuvant chemotherapy. The presence of comorbidities and age were the main complicating factors in typhlitis. As it is an important toxicity and can lead to a worsening of the clinical condition of cancer patients, addressing this issue is essential for a faster diagnosis with the possibility of preventive measures. Conclusion: Therefore, in view of the notorious increase of cases of NE, the perspective of the qualification of the health team is pointed out, for the inclusion of even more specialized professionals capable of contributing and identifying the signs and symptoms related to hematological toxicities, result of chemotherapy treatments.

Introducción: La enterocolitis neutropénica (EN) consiste en la ulceración o necrosis de la mucosa del ciego, íleon terminal y colon ascendente, siendo una condición clínica causada por un evento adverso farmacológico, principalmente en regímenes de quimioterapia. Al tratarse de una afección con una alta tasa de mortalidad, este informe tiene como objetivo contribuir de manera significativa a las discusiones que involucran al EN y la participación del equipo multidisciplinario en el resultado clínico. Relato del caso: Paciente masculino, 75 años, diagnosticado de cáncer de mama, que desarrolló EN después del tratamiento con quimioterapia adyuvante. La presencia de comorbilidades y la edad fueron los principales factores de complicación en Tiflite. Como se trata de una toxicidad importante y puede conducir a un empeoramiento de la condición clínica de los pacientes con cáncer, abordar esta cuestión es fundamental para un diagnóstico más rápido con la posibilidad de medidas preventivas. Conclusión: Por tanto, ante el notable incremento de casos de EN, se apunta la perspectiva de la calificación del equipo de salud, para la inclusión de profesionales aún más especializados capaces de aportar e identificar los signos y síntomas relacionados con las toxicidades hematológicas, un resultado de los tratamientos de quimioterapia.

Enterocolitis Neutropénica en pacientes pediátricos con Leucemia Linfoide Aguda con recaída o refractariedad de su enfermedad de base, durante el período 2016-2017 / Neutropenic enterocolitis in pediatric patients with acute lymphoid leukemia with relapse or refractoriness of their underlying disease, during the period 2016-2017

Introducción: La enterocolitis neutropénica se define como un proceso inflamatorio multifactorial propio de pacientes neutropénicos, caracterizado por el daño trasmural principalmente a nivel del ciego, aunque puede afectar otras áreas como el colon ascendente e íleo. Debido a la dificultad en el diagnóstico y las complicaciones que se presentan se decide realizar un estudio descriptivo de esta patología, sus métodos diagnósticos, manejo y principales complicaciones asociadas. Métodos: Entre octubre del año 2016 y septiembre del año 2017, se realizó un estudio retrospectivo y descriptivo de pacientes diagnosticados de Leucemia Linfoide Aguda (LLA) con recaída o refractariedad de su enfermedad de base que presentaron cuadros compatibles clínica y radiográficamente con enterocolitis neutropénica. El estudio fue realizado en el servicio de oncología pediátrica del Instituto Oncológico Nacional "Dr. Juan Tanca Marengo", Solca Guayaquil. Resultados: Se identificaron 21 casos, de los cuales 17 (80.95%) fueron hombres. Los principales síntomas presentados fueron dolor abdominal, diarrea y fiebre, en el contexto de pacientes neutropénicos, quienes habían recibido tratamiento quimioterápico en los días previos. La ecografía abdominal fue utilizada en todos los casos junto con tomografía abdominal realizada en 6 pacientes como método complementario al diagnóstico. Ningún paciente fue intervenido quirúrgicamente. Todos los pacientes se manejaron de forma conservadora con una evolución favorable. Conclusión: Debe sospecharse esta patología en todo paciente que presente sintomatología compatible con dolor abdominal, asociando fiebre o diarrea y que hubiere recibido tratamiento quimoterápico en los días previos. Solicitando de forma urgente los estudios complementarios necesarios para el diagnóstico y debiendo ser manejado de forma integral. Reservándose el tratamiento quirúrgico ante cuadros con una evolución desfavorable.

Introduction: Neutropenic enterocolitis is defined as a multifactorial inflammatory process typical of neutropenic patients, characterized by transmural damage mainly at the level of the cecum, although it can affect other areas such as the ascending colon and ileus. Due to the difficulty in the diagnosis and the complications that are presented, a descriptive study of this pathology, its diagnostic methods, management and main associated complications is carried out. Methods: Between October 2016 and September 2017, a retrospective and descriptive study of patients diagnosed with Acute Lymphoblastic Leukemia (ALL) with relapse or refractoriness of their underlying disease who presented clinically and radiographically compatible conditions with neutropenic enterocolitis was performed. The study was carried out in the pediatric oncology service of the National Oncological Institute "Dr. Juan Tanca Marengo ", Solca Guayaquil. Results: A total of 21 cases were identified, 17 (80.95%) of which were male. The main symptoms presented were abdominal pain, diarrhea and fever, in the context of neutropenic patients, who had received chemotherapy in the previous days. Abdominal ultrasound was used in all cases together with abdominal tomography performed in 6 patients as a complementary method to the diagnosis. No patient was operated on. All patients were managed conservatively with a favorable evolution. Conclusion: This pathology should be suspected in any patient who presents symptoms compatible with abdominal pain, associated with fever or diarrhea and who had received chemotherapy in the previous days. The complementary studies necessary for the diagnosis must be requested urgently, and the patient must be managed in an integral manner. Reserving the surgical treatment for patients with an unfavorable evolution.

Management of acute colorectal diseases in febrile neutropenic patients / Tratamento das doenças colorretais agudas no paciente neutropênico febril

Patients with hematologic malignancies are susceptible to serious complications due to immunosuppression. Neutropenic-related infection is one of the major causes of morbidity and mortality in this group of diseases. Febrile neutropenia is a common complication of the hematologic neoplasm itself or chemotherapy, and has worse prognosis if prolonged (lasting more than 7 days) or severe (neutrophil count below 500 cells per µL). Among the usual sites of infection, we highlight the neutropenic enterocolitis and perianal infection as gastrointestinal complications of greater interest to the colorectal surgeon. Although most cases respond to conservative treatment, a portion of patients will need surgery for complete recovery. (AU)

Os pacientes com neoplasias hematológicas estão sujeitos a uma séria de complicações devido à imunossupressão. Infecção é umas das principais causas de morbidade e mortalidade nesse grupo de doenças. A neutropenia febril é uma complicação frequente da própria doença onco-hematológica ou da quimioterapia, e apresenta pior prognóstico se prolongada (duração acima de 7 dias) ou severa (contagem de neutrófilos inferior a 500 células por microlitro). Dentre os focos de infecção mais comuns destacamos a enterocolite neutropênica e a infecção perianal como complicações de maior interesse para o cirurgião colorretal. Apesar de grande parte dos casos apresentar boa resposta ao tratamento conservador, uma parcela de pacientes necessitará de cirurgia para completa recuperação.

Enterocolitis neutropénica: reporte de un caso en un paciente con SIDA / Neutropenic enterocolitis report of an AID’s patient case

La enterocolitis neutropénica es una enteropatía necrotizante en pacientes con neutropenia severa relacionada con tratamientos quimioterápicos. Se presenta el caso de un paciente HIV positivo que desarrolló una enterocolitis neutropénica en el contexto de un tratamiento quimioterápico por Linfoma de Hodgkin. Presentaba leucopenia 400 leucocitos/mm3 y cuadro clínico compatible. La ecografía mostró engrosamiento de las paredes del ciego, del colon ascendente, y del íleon terminal. No hubo aislamiento microbiológico. Recibió tratamiento empírico con cefepime, vancomicina, y metronidazol con buena respuesta clínica y ecográfica. En el paciente con SIDA, diversas entidades pueden presentarse con dolor abdominal y engrosamiento de las paredes intestinales, como por ejemplo Citomegalovirus, Clostridium difficile, tuberculosis, histoplasmosis y linfomas, entre otras. El avance tecnológico, y las características ponderales de estos pacientes (bajo peso) permiten utilizar transductores de alta frecuencia para evaluar el tracto gastrointestinal y detectar mínimas lesiones en otros órganos abdominales, aportando al diagnóstico diferencial.

Diarrhea in neutropenic children with cancer: an Egyptian center experience, with emphasis on neutropenic enterocolitis

Diarrhea is a frequent complication in patients with cancer. It may be caused by several factors including conventional gastrointestinal pathogens, suppression of normal intestinal flora as well as noninfectious causes such as mucositis and bowel ischemia, with neutropenic enterocolitis [NE] being the most serious. To study diarrhea in neutropenic cancer patients in the pediatric age group, with its underlying etiologies and risk factors especially the bacterial causes with special concern on NE. The study was carried out at the Pediatric Hematology and Oncology Units, Zagazig University Hospitals, Egypt, from Januray 2009 to September 2010. Neutropenic cancer patients who developed diarrhea were grouped into 2 groups: group [1], with NE, and group [2], with neutropenic diarrhea rather than NE, On the first day of diarrhea, patients were subjected to: complete blood count, blood cultures [if febrile], stool microscopy [for red and white blood cells, ova and parasites], and stool culture [for specific pathogens]. Abdominal ultrasonography was carriad out within 3 days of the onset of diarrhea. A total of 200 children

A Case of Ischemic Colitis Associated with Paclitaxel Loaded Polymeric Micelle (Genexol-PM(R)) Chemotherapy / 결핵및호흡기질환

Paclitaxel has been widely used for treating many solid tumors. Although colonic toxicity is an unusual complication of paclitaxel-based chemotherapy, the reported toxicities include pseudomembranous colitis, neutropenic enterocolitis and on rare occasions ischemic colitis. Genexol-PM(R), which is a recently developed cremophor-free, polymeric micelle-formulated paclitaxel, has shown a more potent antitumor effect because it can increase the usual dose of paclitaxel due to that Genexol-PM(R) does not include the toxic cremophor compound. We report here on a case of a 57-year-old man with advanced non-small cell lung cancer and who developed ischemic colitis after chemotherapy with Genexol-PM(R) and cisplatin. He complained of hematochezia with abdominal pain on the left lower quadrant. Colonoscopy revealed diffuse mucosal hemorrhage and edema from the sigmoid colon to the splenic flexure. After bowel rest, he recovered from his symptoms and the follow-up colonoscopic findings showed that the mucosa was healing. Since then, he was treated with pemetrexed monotherapy instead of a paclitaxel compound and platinum.

Fatal Neutropenic Enterocolitis during Pegylated Interferon and Ribavirin Combination Therapy for Chronic Hepatitis C Virus Infection

It is known that neutropenia caused by combination pegylated interferon plus ribavirin therapy for hepatitis C virus (HCV) infection is well tolerated and carries a negligible risk of infection. Neutropenic enterocolitis is encountered most frequently in patients with hemato-oncologic diseases who are undergoing intensive chemotherapy. However, little information exists regarding this life-threatening event in the setting of HCV therapy. We present here an unusual case of fatal neutropenic enterocolitis in a cirrhotic patient receiving combination therapy for HCV infection. This is the first report of a death from neutropenic enterocolitis associated with treatment for chronic HCV infection. The present case suggests that caution should be exercised when continuing HCV therapy in neutropenic patients with advanced fibrosis, and the decision to maintain such therapy should be balanced against the potential for serious adverse events.

Neutropenic enterocolitis in breast cancer patient after taxane-containing chemotherapy.

Neutropenic enterocolitis or typhlitis (from the Greek typhlon, meaning caecum) is defined as a necrotizing colitis with inflammation of the cecum and surrounding tissues. Although this condition occurs primarily in severely myelosuppressed and immunosuppressed patients with leukemia, it may also occur in those with other advanced malignancies receiving myelosuppressive chemotherapy. It has been described most recently in patients with solid tumors who receive taxane-based therapy. A 60-year old woman with medullary breast cancer stage IIIB underwent neoadjuvant chemotherapy with TAC (doxetaxele 100 mg/m2, doxorubicin 50 mg/m2 and cyclophosphamide 600 mg/m2). Sixth day after TAC chemotherapy, she had abdominal pain and vomiting. Abdomen CT scan showed diffuse circumferential thickening of ileum wall typical for ileitis, narrowing of the lumen, disturbance of peristaltic. This abdomen CT scan was thought as abnormality pictures of neutropenic enterocolitis. Neutropenic enterocolitis should be considered in patients with abdominal symptoms especially during the granulocyte nadir following chemotherapy. Increased awareness of this rapidly progressive and potentially fatal disease leads to accurate diagnosis and the prompt treatment that can decrease morbidity and mortality.

[Fanconi anemia complicated by neutropenic enterocolitis]

Neutropenic enterocolitis [NEC] also known as typhlitis is an acute, life-threatening inflammation of the small and large bowel often seen in patients with leukaemia undergoing cytotoxic chemotherapy; occasionally this syndrome could present in other immunocompromised patients. To report an unusual case of fanconi anemia complicated by neutropenic enterocolitis. We report a case of a 13-year-old boy affected by Fanconi anemia with severe neutropenia and who presented Neutropenic enterocolitis. Abdominal ultrasonography showed thickening of cecum and ascending colon of 1.18cm. The outcome was favourable with medical management. Neutropenic enterocolitis in Fanconi anemia is a rare and a severe illness; however the outcome is improved with early management

Outcome of typhlitis in children with cancer / 소아과

PURPOSE: Neutropenic enterocolitis is an acute, life-threatening inflammation of the small and large bowel, often seen in children with malignancies during periods of prolonged or severe neutropenia. The optimal management for typhlitis in pediatric oncology patients has been debateful between operative and nonoperative approaches. The purpose of this study was to review the outcome of medical management of patients who were diagnosed as typhlitis. METHODS: The records of 207 pediatric cancer patients who were diagnosed and treated at the pediatric department of Yeungnam University Hospital for cancer between August, 2002 and July, 2007 were reviewed. RESULTS: Among 207 patients, 12 (5.7%) children aged 9 to 14 years, were diagnosed clinically to have typhlitis. Clinical symptoms and signs of patients were fever, abdominal pain and tenderness, diarrhea, vomiting and rebound tenderness. Bowel-wall thickening (> 4mm) was seen on CT or ultrasonography. All patients were treated with antibiotics combinations of teicoplanin, carbapenem, aminoglycoside, or other third generation cephalosporin and metronidazole or clindamycin. Eight patients were treated with additional antifungal agents. Other supportive management included bowel rest, total parenteral nutrition, and G-CSF administration. All patients recovered completely and did not need any surgical management. CONCLUSION: Early diagnosis and aggressive supportive treatment appears to be important for complete recovery and survival of typhlitis.

Neutropenic enterocolitis.

We report a case of neutropenic enterocolitis diagnosed on computerized tomography abdomen in a 56-year-old man having high-grade non-Hodgkin's lymphoma. After appropriate management, the patient recovered completely.

Typhlitis due to propylthiouracil in a patient with hyperthyroidism / 대한내과학회지

Typhlitis is one of the most ominous complications in immunocompromised patients. Neutropenic enterocolitis or typhlitis is a clinical syndrome characterized by fever, diarrhea and abdominal pain that occurs in neutropenic patients. It has been reported as a complication of childhood leukemia, but is now known to occur in adults with solid malignancies, acquired immunodeficiency syndrome (AIDS) or bone marrow transplantation (BMT). The association of typhlitis and propylthiouracil has not been previously reported. We report a case of a 42-year-old female patient with typhlitis due to propylthiouracil patient with hyperthyroidism.

Neutropenic Enterocolitis after Chemotherapy for Colon Cancer

Neutropenic enterocolitis is observed in approximately 10~46% of patients with acute leukemia, as well as in patients with other diseases, like acquired immunodeficiency syndrom (AIDS), that lead to profound neutropenia. Patients who become neutropenic after combined chemotherapy are at special risk of developing neutropenic enterocolitis. With the recently increasing numbers of patients with solid tumors treated with high-dose chemotherapy, the frequency of this disease is expected to increase. However, this disease has been rarely reported in patients with colon cancer treated with leucovorin and 5-fluorouracil for adjuvant chemotherapy. We report a case of neutropenic enterocolitis after a treatment of 5-fluorouracil and leucovorin for sigmoid colon cancer.

Enterocolitis neutropénica: revisión sistemática de casos publicados / Systematic review of case reports concerning adults suffering from neutropenic enterocolitis

Introducción: La enterocolitis neutropénica (ECN) es una entidad clínico patológica bien reconocida que amenaza habitualmente la vida y se asocia con diversas neoplasias sólidas y hematológicas y con la anemia aplásica.Objetivo: Evaluar la mortalidad global de la ECN, describir los hallazgos clínicos más frecuentes y las intervenciones terapéuticas reportadas en la literatura médica, con la finalidad de generar hipótesis acerca de los factores que influyen sobre la mortalidad y en la realización de intervenciones quirúrgicas.Materiales y métodos: Se realizaron búsquedas avanzadas en las bases de datos Medline, Embase, Lilacs y en el motor general Google; además, se utilizaron como estrategias adicionales, búsquedas manuales en diversas revistas. Los reportes fueron considerados según la definición del caso teniendo en cuenta criterios específicos para inclusión y exclusión.Resultados: Se seleccionaron 228 casos; 109 fueron casos individuales y 40 reportes correspondieron a series de casos. La comparación de los datos obtenidos a partir de los reportes individuales y de las series de casos no reveló diferencias significativas respecto de la mortalidad, intervenciones quirúrgicas, edad y sexo. Se encontró una mortalidad mayor en las mujeres (2=7,51 p=0,006) comparadas con los hombres (50porciento. No se identificaron diferencias significativas entre las combinaciones de antibióticos respecto de la mortalidad (2=12,85 df 13 p=0,45). La mortalidad (2=3,89 df 1, p=0,049), las intervenciones quirúrgicas (2=7,64 df 1, p=0,006) y la duración de la diarrea (2=4,71 df 1, p=0,043) fueron significativamente diferentes en el 26,4porcientondividuos que fueron tratados con antifúngicos; el 81porciento pcientes que no recibieron estos medicamentos murieron, en comparación con el 19porcientoujetos en que se reportó la utilización de antimicóticos.Conclusión: La evidencia sugiere que los agentes antifúngicos deben ser usados tempranamente en los pacientes que padecen ECN. Sin embargo, esta hipótesis debe ser evaluada en experimentos clínicos multicentricos con asignación aleatoria.

Neutropenic enteropathy.

Neutropenic enteropathy (NE) is used to describe the inflammation of the bowel in neutropenic patients under aggressive chemotherapy, mainly for lymphoproliferative and hematologic malignancies. Surgical intervention may be required in patients with the advent of the disease. We report our experience in 7 children with NE who had to be treated surgically. Absolute neutrophil counts were less than 1000/mm3 in all, with positive blood cultures in five patients. Four patients recovered with rapid resolution of neutropenia, while three patients died with persistent neutropenia.

Neutropenic Enterocolitis in Acute Myelogenous Leukemia

Neutropenic enterocolitis is an acute life-threatening, necrotizing inflammation of cecum and terminal ileum often seen in leukemia and lymphoma during periods of prolonged or severe neutropenia. It has been also referred to as necrotizing enterocolitis, ileocecal syndrome, or typhlitis (from the Greek word typhlon meaning cecum). The pathophysiology of the neutropenic enterocolitis is unknown but is believed to be multifactorial. The clinical symptoms of neutropenic enterocolitis are nonspecific including fever, abdominal pain (often right lower quadrant), abdominal distension, diarrhea, bloody stools, nausea, and vomiting. So acute appendicitis is should be included in the differential diagnosis. The early signs and symptoms are nonspecific and it may rapidly lead to intestinal perforation. The definite management of neutropenic enterocolitis is contrversial. but the prognosis is likely to be good with early diagnosis and proper management. We report one case of neutropenic enterocolitis in acute myelogenous leukemia with literature review.

Neutropenic Enterocolitis with Liver Abscess in a Young Patient with Leukemia after Chemotherapy

Neutropenic enterocolitis is a serious complication of chemotherapy for malignancies such as acute leukemia or lymphoma. The acute inflammatory disease may involve the terminal ileum, cecum and ascending colon. Although conservative care is recommended as the primary treatment modality, surgical intervention is essential for intestinal perforations, abscesses, or bleeding. We experienced a case of neutropenic enterocolitis with a liver abscess in a young leukemia patient. A 13-year-old boy with acute myelogenous leukemia had completed two cycles of chemotherapy (Arabinoside 300 mg, Dactinomycin 40 mg, VP-16 150 mg, 6- mercaptopurin 60 mg, dexametasone 3 mg). Ten days after completing the second cycle he had abdominal pain, low abdominal tenderness and a high fever. The WBC count in the peripheral blood was 210 cell/mm3. A CT scan demonstrated wall thickening of the terminal ileum and ascending colon, as well as 5 cm, and 6 cm sized homogeneous low-density areas in both hepatic lobes. A presumptive diagnosis was neutropenic enterocolitis with a liver abscess. The patient was managed conservatively with fluid resuscitation, a bowel rest, and broad-spectrum antibiotics. Twenty-five days later his abdominal pain was abruptly aggravated. The CT scan and Chest X-ray demonstrated free air in the peritoneal cavity. An emergency laparotomy was performed under a diagnosis of peritonitis with an intestinal perforation. The laparotomy show that, there were perforations at the pylorus of the stomach, and full thickness necrosis at multiple segments of the small bowel. Primary closure of the stomach, a segmental resection and an end-to-end anastomosis of the small bowel, and ileostomy were performed. However, postoperative leakage developed at the stomach. The patient recovered with supportive management. The patient had a third chemotherapy series 3 months after surgery. Three days after completing the third cycle, the patient developed peritonitis. A pyloric re-perforation of the stomach was observed on the laparotomy. Postoperative leakage developed after the primary closure of the stomach. The patient died of sepsis 54 days later. Therefore, intensive monitoring and close collaboration between the hematologist and the surgeon is essential for patients with neutropenic enterocolitis. Postoperative complications are quite common and can be fatal in patients with neutropenic enterocolitis that develops after chemotherapy.

Neutropenic Enterocolitis with Liver Abscess in a Young Patient with Leukemia after Chemotherapy

Neutropenic enterocolitis is a serious complication of chemotherapy for malignancies such as acute leukemia or lymphoma. The acute inflammatory disease may involve the terminal ileum, cecum and ascending colon. Although conservative care is recommended as the primary treatment modality, surgical intervention is essential for intestinal perforations, abscesses, or bleeding. We experienced a case of neutropenic enterocolitis with a liver abscess in a young leukemia patient. A 13-year-old boy with acute myelogenous leukemia had completed two cycles of chemotherapy (Arabinoside 300 mg, Dactinomycin 40 mg, VP-16 150 mg, 6- mercaptopurin 60 mg, dexametasone 3 mg). Ten days after completing the second cycle he had abdominal pain, low abdominal tenderness and a high fever. The WBC count in the peripheral blood was 210 cell/mm3. A CT scan demonstrated wall thickening of the terminal ileum and ascending colon, as well as 5 cm, and 6 cm sized homogeneous low-density areas in both hepatic lobes. A presumptive diagnosis was neutropenic enterocolitis with a liver abscess. The patient was managed conservatively with fluid resuscitation, a bowel rest, and broad-spectrum antibiotics. Twenty-five days later his abdominal pain was abruptly aggravated. The CT scan and Chest X-ray demonstrated free air in the peritoneal cavity. An emergency laparotomy was performed under a diagnosis of peritonitis with an intestinal perforation. The laparotomy show that, there were perforations at the pylorus of the stomach, and full thickness necrosis at multiple segments of the small bowel. Primary closure of the stomach, a segmental resection and an end-to-end anastomosis of the small bowel, and ileostomy were performed. However, postoperative leakage developed at the stomach. The patient recovered with supportive management. The patient had a third chemotherapy series 3 months after surgery. Three days after completing the third cycle, the patient developed peritonitis. A pyloric re-perforation of the stomach was observed on the laparotomy. Postoperative leakage developed after the primary closure of the stomach. The patient died of sepsis 54 days later. Therefore, intensive monitoring and close collaboration between the hematologist and the surgeon is essential for patients with neutropenic enterocolitis. Postoperative complications are quite common and can be fatal in patients with neutropenic enterocolitis that develops after chemotherapy.

A Case of Typhlitis in a Neutropenic Patient Presented to Emergency Center

Typhlitis or neutropenic enterocolitis is a life-threatening, necrotizing process of the cecum whose incidence is increasing. Typhlitis presents as fever, abdominal pain, and diarrhea in neutropenic patients. As the incidence of typhlitis increases, emergency physicians must be aware of this rapidly progressive and potentially fatal disease. The definitive management of typhlitis is controversial. The most prudent course for the emergency physician is to initiate aggressive medical management early in the ED. We describe a 25-year-old man with severe neutropenia presented to the emergency department with fever, abdominal pain, diarrhea that began 2days earlier. Abdominal computerized tomography(CT) demonstrated diffuse concentric thickening of the cecal wall, intramural edema, inflammatory bowel changes but no free air and abscess formation. He was recovered by early diagnosis and aggressive medical therapy. We report a case of typhlitis with literature reviews.