Good functional outcome following severe neutropenic enterocolitis and perforation in a 48-year-old woman undergoing chemotherapy for breast cancer.

Neutropenic enterocolitis (NEC) is a life-threatening bowel condition, usually resulting from chemotherapy, with a mortality rate thought to be as high as 50%. Markers of poor prognosis include gastrointestinal perforation and bowel wall thickness radiologically detected to be greater than 10 mm. NEC is associated with severe neutropenia and predominantly affects the large bowel; however, we present a case of severe NEC with oesophageal perforation requiring transfer to a specialist upper gastrointestinal unit for corrective stenting. Despite initial bowel wall thickness of 20 mm in the ascending colon, two discrete episodes of bowel perforation and an inpatient stay totalling 89 days, the patient was discharged with full independence, a good quality of life and a plan for curative mastectomy plus axillary clearance.

Bowel Imaging in Children: Part 2.

The bowel is a challenging abdominal organ to image. A variety of bowel disorders such as congenital, developmental, inflammatory, infectious and neoplastic lesions can affect children and most of them are either unique to this age group or have a distinct clinico-radiological appearance compared to adults. Imaging forms an integral part of management of these disorders. This article will cover inflammatory/infective, neoplastic and miscellaneous disorders affecting the bowel. The authors will highlight the salient imaging features for those entities.

Neutropenic enterocolitis affecting the transverse colon: an unusual complication of chemotherapy.

A 66-year-old woman presented with a 1-day history of sudden onset of generalised abdominal pain associated with fever and vomiting. She was previously diagnosed with left breast cancer 2 months ago and completed a course of chemotherapy 1 week prior to presentation. She was clinically unwell with generalised tenderness in her abdomen. Blood investigations showed severe neutropenia. A CT scan was requested which reported a marked oedematous swelling of the transverse colon with features suggestive of a contained perforation. The decision was made to operate. Intraoperatively, the transverse colon was found to be thickened with omentum adherent focally around the distal third. A right hemicolectomy was performed with an end ileostomy and mucus fistula. The patient made a successful recovery and was discharged within 7 days of presenting. Pathology reported typical features of neutropenic enterocolitis affecting the transverse colon with a normal terminal ileum, caecum and ascending colon.

[Neutropenic enterocolitis after autologous peripheral blood stem cell transplantation in non-Hodgkin's lymphoma - a case report].

Here we report a case of a 59-year-old man who developed neutropenic enterocolitis(NE)after autologous peripheral blood stem cell transplantation for non-Hodgkin's lymphoma in his second complete remission.Four days after transplantation, the patient suffered from diarrhea, abdominal pain, fever, and paralytic ileus.Abdominal computerized tomography scan revealed bowel wall thickening consistent with NE.Owing to his poor performance status, only medical management, including antibiotics and bowel rest, was administered, and the patient died 18 days after transplantation.Although NE after autologous peripheral blood stem cell transplantation is a relatively rare complication, it is important to be aware that this condition can occur as one of the early complications in stem cell transplantation.

CT features of neutropenic enterocolitis in adult patients with hematological diseases undergoing chemotherapy.

PURPOSE: This study investigates the features of neutropenic enterocolitis (NE) in adults. MATERIALS AND METHODS: Chart and radiology report reviews were used to identify neutropenic patients with hematological diseases undergoing chemotherapy, who had CT scans for the clarification of abdominal symptoms between October 2003 and October 2009. Patients with any cause for enteritis other than NE were excluded. The scans were analyzed with respect to imaging features and location. Morphological findings were correlated with clinical data. RESULTS: Thirty-one patients with NE (median age 46 years; range 20 - 75) could be identified. Wall thickening and hyperemia could be found in all bowel segments from jejunum to rectum. The right hemicolon was the most frequent location in 19 patients (61%). Involvement was generalized in 6 patients (19%) and segmental in 25 cases (81%). The longer the duration of neutropenia, the more likely generalized involvement of the bowel was. In 8 patients who underwent CT follow-up, the appearance of bowel segments had completely (n = 5) or partially (n = 3) returned to normal at the latest 14 days after the initial diagnosis. Eight patients (26%) died 1 - 78 days after NE, 7 of who had previously recovered from NE. CONCLUSION: CT findings are useful for the diagnosis of NE and should be considered even in the presence of isolated small bowel involvement. The terms NE and typhlitis should thus no longer be used synonymously.

Neutropenic enterocolitis in children and young adults with cancer: prognostic value of clinical and image findings.

Intensive chemotherapy regimens can result in severe toxicities, particularly those that involve the digestive systems, leading to morbidity and mortality in this group of patients. Acute enterocolitis can be a frequent complication. The authors performed a retrospective review or patients treated at their institution to ascertain the prognostic value of the clinical symptoms and signs of acute enterocolitis, the corresponding abdominal ultrasonographic findings, and the impact of previous chemotherapy. Amongst 1159 patients with cancer treated at the Centro Infantil Boldrini from 2003 to 2007, 188 (16.2%) patients had 1 or more episode of enterocolitis. An intestinal wall thickness of >or=3 mm on ultrasound was considered diagnostic of enterocolitis. There were 231 episodes of enterocolitis with a death rate of 11.7%. Previous therapy with cytarabine and the presence of abdominal distention affected survival. An intestinal wall thickness of >or=10 mm in the ultrasonographic examination was associated with greater mortality. In multivariate analysis, age, gender, tumor type, degree of neutropenia, intestinal wall thickness, and number of intestinal segments were not statistically significant difference. In children and young adults with cancer and enterocolitis, the clinical findings of 4 or more symptoms and presence of abdominal distention were associated with higher risk of death. Use of cytarabine and an intestinal wall thickness of >or=10 mm were associated with a higher death rate.

Imaging of the gastrointestinal complications of systemic chemotherapy.

Gastrointestinal complications of chemotherapy may be serious and potentially life-threatening. Familiarity with and awareness of the potential complications associated with various chemotherapeutic agents/regimens is paramount to enable accurate and timely diagnosis. In this article we review the radiological manifestations of the most notable gastrointestinal complications associated with chemotherapeutic administration.

Challenges in surgical management of abdominal pain in the neutropenic cancer patient.

BACKGROUND: Abdominal pain in neutropenic cancer patients presents a unique clinical challenge for surgeons. The purposes of this retrospective study were to characterize the clinicopathologic factors associated with the presentation of neutropenia and abdominal pain, examine the treatment strategies used, and define associated outcomes for these patients. METHODS: We identified patients with concomitant neutropenia (absolute neutrophil count <1000 cells/microL) and abdominal pain who had been evaluated by surgical oncologists over a period of more than 6 years. A Cox proportional hazards regression model was used to analyze the association between clinicopathologic factors and overall survival time. RESULTS: Sixty patients were included in this analysis. After our clinical and radiographic evaluations, we determined that the most frequent causes of the abdominal pain were neutropenic enterocolitis (28%) and small bowel obstruction (12%); the cause remained uncertain in 35%. Surgical interventions had been performed in 9 patients. The 30- and 90-day mortality rates for all patients were 30% and 52%, respectively. Multivariate analysis revealed that severe sepsis, a relatively long duration of neutropenia, and the lack of surgical intervention were significant adverse prognostic factors for overall survival. CONCLUSIONS: Abdominal pain as a symptom in neutropenic patients continues to be a diagnostic and therapeutic challenge and is associated with a high mortality rate. Based on our results, we conclude that efforts should focus on improving neutrophil counts and on treating the frequent and serious comorbidities found in these patients. Surgery should be delayed, when possible, to allow for neutrophil recovery.

The acute abdomen in the immune compromised host.

Recent advances in transplantation, oncology and AIDS therapy have greatly increased life expectancies of patients diagnosed with malignancy, auto-immune disorders and organ failure. However, as this immune compromised population grows, complications of such therapies have become a major source of morbidity and mortality. Classical clinical and laboratory evidence of intra-abdominal pathology may be absent in the immune compromised host. Consequently, the radiologist is increasingly called upon to diagnose acute intra-abdominal complications associated with immunodeficiency. This review explores the aetiology of the acute abdomen in the immune compromised host. The typical radiological appearances of the commonest conditions are illustrated. The challenges and limitations in the radiological diagnosis of these conditions are discussed.

[Neutropenic enterocolitis in adult patients with acute leukemia or stem cell transplant recipients: study of 7 cases]. / Enterocolitis neutropénica en adultos con leucemia aguda o receptores de un trasplante de progenitores hematopoyéticos: estudio de 7 casos.

BACKGROUND AND OBJECTIVE: Neutropenic enterocolitis (NE) is a complication arising in neutropenic patients with acute leukemia or solid tumours while treated with intensive chemotherapy. The optimal therapeutic procedures have not been well established. PATIENTS AND METHOD: Seven cases of NE diagnosed and treated in a tertiary hospital between 2000 and 2007 are described. Their clinico-biological characteristics, therapeutic procedures and evolution were analysed retrospectively. RESULTS: Five of the patients were males, their median age was 39 years. Acute myeloblastic leukemia was the most frequent diagnosis (5 cases). Two other patients had received an stem cell transplantation. Abdominal pain was present in all patients, diarrhoea in 6, and fever in 5. Microorganisms were isolated from blood cultures in 4 cases (Clostridium septicum, Escherichia coli, Pseudomonas aeruginosa and Aeromonas hydrophila). Abnormal mural thickening of the caecum was observed in the 6 cases in which a computed tomography scan could be performed. The median mural thickness at its maximum section was 11 mm (range: 8-16). All patients first received medical treatment with wide spectrum antibiotics and intestinal rest, and abdominal surgery was indicated in 6 cases after a median time from first symptom of 4 days (range: 0-12). NE was confirmed histologically in all 6 patients. Five patients required admission in Intensive Care Unit and 2 (29%) died as a result of NE. CONCLUSIONS: NE is a severe complication of patients with hematologic malignancies submitted to intensive chemotherapy or receiving stem cell transplantation. Abdominal computed tomography scan is the most valuable diagnostic tool. Prompt surgical intervention may improve the prognosis in patients with NE.

Systematic review of case reports concerning adults suffering from neutropenic enterocolitis.

INTRODUCTION: Neutropenic enterocolitis (NEC) is a well recognised clinical-pathological and life-threatening complication in patients suffering from several conditions, including solid and haematological malignancies or aplastic anaemia. OBJECTIVE: This review was aimed at evaluating overall NEC mortality rate, describing clinical diagnostic findings and therapeutical interventions reported in the literature and generating a hypothesis regarding factors influencing mortality and surgical intervention. MATERIALS AND METHODS: An advanced search was made in Medline, Embase, Lilacs and Google. Additional strategies included manual search of specific journals. Reports were considered if they described case definition, inclusion and exclusion criteria. RESULTS: 275 cases were selected; 109 were from individual data and 40 from grouped data. Comparing data between case reports and case series revealed no significant differences related to mortality, surgical intervention, sex or age. Higher mortality (chi2 = 7.51 p = 0.006) was found in women (50%) compared to men (28%). No significant difference was found between antibiotic combinations and mortality (chi(2) = 12.85 df 13 p = 0.45). Mortality (chi2 = 3.89 df 1, p = 0.049), surgical intervention (chi2 = 7.64 df 1, p = 0.006) and duration of diarrhoea (chi2 = 4.71 df 1, p = 0.043) were significantly different in 26.4% of individuals using antifungal agents; death occurred in 81% of patients! who did not receive such medication compared to 19% individuals reported as being treated with antifungal agents. CONCLUSION: The current evidence suggests that antifungal agents should be used early in patients suffering from NEC. However, this hypothesis must be evaluated in multi-centric, randomised controlled trials.

Sonographic signs of neutropenic enterocolitis.

AIM: To investigate the sonographic features at time of diagnosis and follow-up in patients with neutropenic enterocolitis. METHODS: The sonographic findings in 14 patients with neutropenic enterocolitis were described and evaluated regarding symptoms and clinical outcome. RESULTS: In all patients with neutropenic enterocolitis, the ileocoecal region was involved with wall thickening >10 mm. A transmural inflammatory pattern, hypervascularity of the thickened bowel wall and free abdominal fluid were the common findings. The sonographically revealed thickness of the bowel wall was associated with lethal outcome (P<0.03). In the 11 surviving patients,the improvement of clinical symptoms was accompanied by progressive reduction of intestinal wall thickness. CONCLUSION: High-end sonography of the bowel is a helpful tool for diagnosis,assessment of prognosis and follow-up of patients with neutropenic enterocolitis.The ultrasonographically revealed bowel thickness reflects the severity and the course of the disease, and seems to be predictive for the clinical outcome.

Neutropenic colitis during standard dose combination chemotherapy with nedaplatin and irinotecan for testicular cancer.

A 54-year-old man received combination chemotherapy with nedaplatin and irinotecan as salvage chemotherapy for refractory non-seminomatous testicular cancer. The patient developed abdominal pain and high fever on Day 21 after the initiation of chemotherapy. Computed tomography revealed thickening of the terminal ileum wall and paralytic ileus. The patient recovered with intensive supportive management including broad-spectrum antibiotics, bowel rest with gastric intubation and intravenous gamma-globulin. Neutropenic colitis has been thought to be a serious gastrointestinal complication associated with chemotherapy for hematological malignancy. The mortality rate is as high as 21-48% according to a recent review. The present case indicates that the neutropenic colitis can occur under neutropenic conditions induced by the standard-dose chemotherapy for solid cancer.

[Ladd laparoscopic procedure in the neonate]. / Operación de Ladd laparoscópica en el recién nacido.

The treatment of the intestinal malrotation with or without midgut volvulus with the Ladd procedure for laparoscopic way has been proposed by several authors since 1995. We carry out this treatment in a patient of 15 days old with intestinal malrotation and midgut volvulus. After clinical and radiologic diagnosis, the procedure consisted in the careful counterclock reduction of the volvulus, division of the Ladd's bands, incision of the common mesentery and appendectomy. The jejunum and ileum was positioned on the rigth and the colon on the left in the abdominal cavity. The postoperative evolution was appropiate. We recommend the laparoscopic Ladd's procedure like an alternative in the patients with midgut volvulus that fulfill minimum approaches during the preoperative study that allow to carry out the surgery with security.

[Isolated edematous swelling of Bauhin's valve -- sonographically suspected diagnosis of a rare ileocoecal disease]. / Isolierte ödematöse Schwellung der Bauhin-Klappe -- Sonographische Verdachtsdiagnose einer seltenen ileozäkalen Erkrankung.

Isolated edematous swelling of Bauhin's valve is a rare finding in cases of non-specific abdominal complaints in the lower right abdominal quadrant. The differential diagnosis includes entities such as tumours, chronic gastrointestinal inflammation and ileocoecal intussusception as well as specific infections, all of which require individual therapy. Based on two current cases and a review of the literature, aetiology, clinical picture and diagnostic findings of isolated edema of the ileocoecal valve are described. The typical ultrasound findings are presented. Due to its potential of excluding other diseases, modern ultrasound offers promising results in the case of isolated edematous swelling of Bauhin's valve.

[Clinical and microbiological characteristics of neutropenic enterocolitis in adults with blood cancer in the National Cancer Institute of Bogota D.C. (Colombia)]. / Características clínicas y microbiológicas de la colitis neutropénica en adultos con neoplasias hematológicas del Instituto Nacional de Cancerología de Bogotá D.C. (Colombia).

OBJECTIVES: This study describes the clinical, epidemiological and microbiological characteristics of adult patients with blood cancer and neutropenic enterocolitis treated in the Instituto Nacional de Cancerologia (National Cancer Institute) in Bogota, Colombia. METHODS: The clinical histories of 692 adult patients hospitalized in the Instituto Nacional de Cancerologia between 1997 and 2001 with a diagnosis of leukemia or lymphoma were reviewed. Thirty-five of these cases met the criteria for probable or confirmed neutropenic enterocolitis. RESULTS: Twenty-two cases were confirmed and the remaining 13 were probable neutropenic enterocolitis. All patients were undergoing chemotherapy and all presented watery diarrhea and abdominal pain. In addition, 17% had melena and 25% severe vomiting. Eight of 26 stool cultures (30%) and 17 of 32 (58%) blood cultures were positive for potentially pathogenic microorganisms, particularly gram-negative bacilli. Three patients with probable neutropenic enterocolitis and ten confirmed cases died (37%); mortality was higher among patients who were managed surgically. CONCLUSION: Neutropenic colitis presents as a multifactorial syndrome in patients with blood cancer undergoing cytotoxic therapy with agents such as cytosine arabinoside, etoposide, vincristine, cyclophosphamide and corticoids. This highly lethal complication is partly due to infections caused by gram-negative bacilli.

ED presentation of neutropenic enterocolitis in adult patients with acute leukemia.

The purpose of this study was to investigate the initial clinical features and subsequent outcomes in patients with adult leukemia with typhlitis or neutropenic enterocolitis. A retrospective review of 10 episodes of neutropenic enterocolitis in nine patients (age range, 21-71 years) with acute leukemia from March 1, 1990, through February 28, 2002, was conducted. In clinical presentations, fever appears in all patients, followed by abdominal pain or tenderness (90%) and diarrhea (60%), respectively. In particular, three cases were coincidentally diagnosed as leukemia before any chemotherapy. The most common diagnostic modality used for the diagnosis of neutropenic enterocolitis was computed tomography (CT) scan (seven episodes). Medical treatments, including broad-spectrum antibiotics, bowel rest, and total parenteral nutrition, were applied to seven patients. Laparotomy with bowel resection was performed on two patients with bowel necrosis and severe peritonitis. Of all nine cases, six were fatal as a result of sepsis, a common complication of neutropenic enterocolitis. As the incidence of neutropenic enterocolitis increases in patients with acute leukemia, EPs should be alert and make an early diagnosis of this rapidly deteriorated and life-threatening disease.