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

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.

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.

Neutropenic Enterocolitis: Case report and literature review.

Typhlitis, is also known as neutropenic enterocolitis, affects the cecum and distal ileum. It was frequently encountered in pediatric patients who were undergoing treatment for leukemia. Nonetheless, it can affect adult patients, regardless of the cause of the immunosuppression. We report the case of a 20-year-old patient who was receiving chemotherapy for Osteosarcoma, who had a 6-day history of nausea and vomiting, fever sensation, diarrhea, and diffuse abdominal pain. Physical examination was relevant for hemodynamic instability, a distended and tender abdomen predominantly in the right iliac fossa. The laboratory workup showed severe neutropenia, thrombocytopenia, and electrolyte disturbances. The image studies evidenced edema of the ascending colon and cecum. Treatment was started with vasopressor support, correction of electrolyte alterations, blood cell and platelet transfusion, G-CSF, hydration, broad spectrum antibiotic therapy, initially with adequate clinical and laboratory response. After a few days, he presented lower gastrointestinal bleeding which was treated by conservative management. In conclusion, typhlitis must be suspected in every patient developing neutropenia as a reaction to chemotherapy and who also presents gastrointestinal symptoms, such as nausea, vomiting, diarrhea, and intense abdominal pain.

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.

Factors associated with emergent colectomy in patients with neutropenic enterocolitis.

PURPOSE: Neutropenic enterocolitis (NEC) is a severe complication of neutropenia. NEC is characterized by segmental ulceration, intramural inflammation, and necrosis. Factors present in patients who underwent colectomy have never been studied. The present study aimed to describe the clinical factors present in patients who underwent emergent colectomy for the treatment of neutropenic enterocolitis. METHODS: Patients admitted with neutropenic enterocolitis from November 2009 to May 2018 were retrospectively analyzed. Logistic regression analysis was used to determine clinical factors associated with emergent colectomy. RESULTS: Thirty-nine patients with NEC were identified. All patients had a hematological disorder. Medical treatment was the only management in 30 (76.9%) patients, and 9 (23.1%) patients underwent colectomy. No differences were found between the treatment groups regarding sex, age, or comorbidities. Patients were more likely to undergo colectomy if they developed abdominal distention (OR = 12, p = 0.027), hemodynamic failure (OR = 6, p = 0.042), respiratory failure (OR = 17.5, p = 0.002), multi-organic failure (OR = 9.6, p = 0.012), and if they required ICU admission (OR = 11.5, p = 0.007). Respiratory failure was the only independent risk factor for colectomy in multivariable analysis. In-hospital mortality for the medical and surgical treatment groups was 13.3% (n = 4) and 44.4% (n = 4), respectively (p = 0.043). CONCLUSIONS: In our study, most NEC patients were treated conservatively. Patients were more likely to undergo colectomy if they developed organ failures or required ICU admission. Early surgical consultation is suggested in all patients with NEC.

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.

Neutropenic Enterocolitis: New Insights Into a Deadly Entity.

Neutropenic enterocolitis (NE) is a deadly ileocecal-based disease seen in patients with a recent history of chemotherapy. As histology is not included in the current diagnostic criteria, the pathologic features of NE are poorly understood. We undertook a multi-institutional study of NE, and report helpful clinical clues, such as immunosuppression (n=20/20), recent chemotherapy (n=17/18), neutropenia (n=16/18) gastrointestinal symptoms (n=19/19), abnormal imaging studies of the cecum/right colon (n=11/14), and positive microbiological studies (n=13/15). Fever (n=9/15) and sepsis (n=8/16) were also common. Pathologically, the cecum/right colon was always involved (n=17/17), but findings were identified in other bowel segments as well. NE lesions consisted of patchy necrosis (n=18/20), infiltrating organisms (n=17/20), hemorrhage (n=15/20), ulcer (n=15/19), edema (n=15/20), and depletion of inflammatory cells (n=15/20). Seventy-nine percent (n=15/19) of patients with histologically confirmed NE died: 47% (n=7/15) of these deaths were attributed to NE and the remainder to the patients' underlying conditions. Importantly, we observed a clinical diagnostic discordancy rate of 35% (n=9/26): 15% (n=3/20) of histologically confirmed NE were clinically unsuspected, and 26% (n=6/23) of clinically suspected NE represented a different disease process. Alternative diagnoses included unspecified colitis, infection, graft-versus-host disease, relapsed malignancy, mycophenolate injury, appendicitis, and ischemia. The causes of death in patients with NE mimics included unrecognized appendicitis and unrecognized graft-versus-host disease. To improve diagnostic accuracy, we propose that histology be required for a diagnosis of "definitive NE," with other clinically suspicious cases reported as "suspicious for NE" until all other possible diagnoses have been reasonably excluded.

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.

[Opportunistic bacteria and microbial flora in children with leukemia and neutropenic enterocolitis]. / Bacterias oportunistas y microbiota en niños con leucemia y enterocolitis neutropénica.

OBJECTIVE: to determine the prevalence of opportunistic microorganisms and microbial flora in neutropenic enterocolitis in oncohematological pediatric patients. METHODS: a prospective and observational study was done. Patients with diagnosis of acute leukemia and neutropenia were included. Stool cultures were taken to identify microorganisms and microbial flora. A χ(2) test with Yates corrections and Fisher exact test were used in the statistical analysis. RESULTS: 21 patients were included (12 male, 57.1 %). The stool cultures showed that 68 % of microorganisms were Gram-negative. The presence of microorganisms Gram-positive was 20 %, 6 % for Candida sp.; 3 % for Cryptosporidium sp.; and in 3 % were acid fast bacilli. Staphylococcus epidermidis, Enterobacter sp., and Escherichia coli were presented in pure culture. No association was found between Gram-positive and Gram-negative microorganisms with age, white cell count or pure or mixed cultures. CONCLUSIONS: although Gram-negative microorganisms were the most frequent, Gram-positive and other microorganisms that are not detected habitually in feces culture were isolated.

Objetivo: determinar la microbiota y la prevalencia de microorganismos oportunistas en niños con leucemia y enterocolitis neutropénica. Métodos: se realizó un estudio prospectivo observacional en pacientes con leucemia aguda y neutropenia. Se tomaron cultivos de heces para identificar la presencia de bacterias y microbiota. Se aplicó estadística descriptiva para su análisis. Resultados: fueron incluidos 21 pacientes (12 hombres, 57.1 %). En 68 % de los coprocultivos se observó desarrollo de microorganismos gramnegativos. La presencia de microorganismos grampositivos fue de 20 %, 6 % de Candida sp., 3 % de Cryptosporidium sp. y en 3 % se observaron bacilos ácido alcohol resistentes. Staphylococcus epidermidis, Enterobacter sp., y Escherichia coli se observaron en cultivo puro. No se encontró asociación entre microorganismos grampositivos y gramnegativos con la edad, el recuento leucocitario ni el cultivo puro o mixto.Conclusiones: aunque los microorganismos gramnegativos fueron los más frecuentes, se aislaron de manera importante grampositivos y otros que no se buscan de rutina en el coprocultivo.

Enterocolitis neutropénica: reporte de un caso en un paciente con SIDA / Neutropenic enterocolitis report of an AIDÆs 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.(AU)

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.

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.

[Prevalence of neutropenic enterocolitis in adults with severe neutropenia and associated mortality.]. / Prevalencia de enterocolitis neutropénica en adultos con neutropenia grave y mortalidad asociada.

BACKGROUND: Neutropenic enterocolitis (NEC) is characterized by inflammatory damage and necrosis of the intestinal mucosa, mainly of the terminal ileum and the cecum. It is more frequent in patients with leukemia and/or undergoing antineoplastic chemotherapy, and the main risk factor is neutropenia <1000/mm3. OBJECTIVE: To know the prevalence of NEC and the mortality associated with it in adults with hematologic conditions and neutropenia <1000/mm3. MATERIAL AND METHODS: All adult patients who were hospitalized for malignant hematologic conditions with neutropenia <1000/mm3 were enrolled in the study; those with neutropenia >1000/mm3 were excluded. The diagnosis of NEC was based on the clinical data and imaging tests (abdominal plain X-rays and CT scan). Demographics of all patients were collected, as well as the data related with the course and treatment of the underlying hematologic condition and the NEC. RESULTS: 117 patients were enrolled in the study; 75.2% of them with some type of acute leukemia. The diagnosis of NEC was made in 8 patients (6.8%). NEC occurred in 10.5% of the patients with acute myeloid leukemia and in 8.0% of those with acute lymphocytic leukemia. Three patients died, which resulted in a 37.5% mortality rate. No association was found between the severity of neutropenia and the onset of NEC or NEC-related mortality. CONCLUSIONS: The prevalence of NEC in patients with hematologic conditions admitted for severe neutropenia is 6.8% and the mortality rate associated with this complication is 37.5%.

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.

[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.

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.

[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.