Diagnosis

Neutropenic enterocolitis

Etiology

Cause [mrf]

• Unknown

• Neutropenia:

  • Chemotherapy

  • Radiation

  • Leukemia

Pathogenesis [2nz][mrf]

1. Cytotoxic drugs (methotrexate, vincristine, Cyclophosphamide, Cytarabine)

   • Mucosal injury

   • Bowel wall edema

   • Ulceration

   • Hemorrhage

2. Immunosuppresion --> Altered bacterial flora and overgrowth of fungi

3. Neutropenia --> reduced mucosal protection --> bacterial/fungal invasion of the bowel wall (transmural inflammation) --> necrosis and perforation

4. Pathogen: Clostridium septicum, Escherichia coli, Kleibsiella pneumoniae, Enterobacter taylorae, Morganella morganii, Streptococcus viridans, Bacillus cereus, gram-positive cocci, enterococci, fungi, and virus

Risk factors

• Chemotherapy for leukemia, myeloproliferative disorders, solid malignant tumors

• Immunosuppression

• Bone marrow transplantation

Complications [mrf]

• Gastrointestinal bleeding

• Bowel perforation --> peritonitis and abscess formation

• Sepsis --> septic shock --> multiorgan failure --> death

Epidemiology

Incidence per 100.000 [kno][whf][pas][hsw][6oc][tnn]

Approach

• Blood test

• Blood gas

• Blood culture

• Clostridium difficile toxin

• Feces culture

• Abdominal x-ray

• Ultrasound abdomen

• CT abdomen

• Colonoscopy

• Biopsy

Diagnostic criteria [psf]

1. Major criteria:

   • Biopsy with typical histology

   • Neutropenia

   • GI symptoms

   • Immunosuppression

   • Chemotherapy

2. Minor criteria:

   • Fever

   • Bowel wall thickenin

   • Positive culture

Treatment

1. Non-operative management: [kno][mrf]

   • Bowel rest

   • Abdominal decompression

   • Parenteral nutritional support

   • Aggressive fluid resuscitation

   • Correction of electrolyte imbalance

   • Blood component transfusion: blood, correction of thrombocytopenia

   • Granulocyte colony-stimulating factor (G-CSF)

     • Severe neutropenia, pneumonia, shock, multiorgan failure, fungal infection

   • Broad-spectrum antibiotics:

     • Cephalosporin + Metronidazole or Vancomycin

     • Antipseudomonal β-lactam antibiotic + aminoglycoside

2. Operative intervention:

   • Bowel perforation --> surgery

   • Uncontrollable hemorrhage --> angiography with embolization or surgery

   • Condition deteriorates despite conservative management --> surgery

Differential diagnoses

Appendicitis, Crohn disease, Cytomegalovirus, Gastroenteritis, Graft-versus-host disease, Infectious colitis, Ischemic colitis, Ogilvie syndrome, Pseudomembranous colitis, Sepsis, Shock, Toxic megacolon, Ulcerative colitis