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Abdominal Complications During Treatment for Pediatric Acute Myeloid Leukemia. J Pediatr Hematol Oncol 2022; 44:220-229. [PMID: 34387627 DOI: 10.1097/mph.0000000000002281] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Accepted: 06/10/2021] [Indexed: 11/26/2022]
Abstract
Acute myeloid leukemia (AML) accounts for 15% to 20% of childhood leukemias. Because of high-intensive therapy, up to 5% of patients suffer from treatment-related mortality (TRM). Abdominal complications are frequent, however, literature on this subject is sparse. We aimed to characterize severe abdominal pain (AP) and hyperbilirubinemia experienced by pediatric AML patients treated according to the Nordic Society of Pediatric Hematology and Oncology (NOPHO)-AML 2004 protocol (n=313). Patients were censored at hematopoietic stem cell transplantation and relapse. Toxicity information was collected prospectively. Additional information was requested retrospectively from the treating centers. Sixteen episodes of hyperbilirubinemia and 107 episodes of AP were reported. The treating centers deemed infection (30%) and typhlitis (18%) as the most frequent causes of AP. Six patients developed appendicitis (2%). Patients experiencing concurrent AP and sepsis had a high risk of TRM (36%, n=4). Eighty percent of episodes with hyperbilirubinemia fulfilled the European Society for Bone and Marrow Transplantation criteria for sinusoidal obstruction syndrome. In conclusion, abdominal complications were frequent with infection considered the predominate cause. Most patients with hyperbilirubinemia fulfilled the criteria for sinusoidal obstruction syndrome. AML treatment might be associated with appendicitis. Patients suffering from concurrent AP and sepsis had a high risk of TRM indicating that high awareness of abdominal complications is essential to reduce mortality, especially during sepsis.
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Wright Z, Essien F, Renshaw J, Wiggins M, Brown A, Osswald M. Appendiceal disease in hematopoietic cell transplantation. Clin Case Rep 2022; 10:e05047. [PMID: 35140939 PMCID: PMC8813669 DOI: 10.1002/ccr3.5047] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2021] [Revised: 10/20/2021] [Accepted: 10/21/2021] [Indexed: 12/29/2022] Open
Abstract
Appendiceal diseases are rare reported complications during hematopoietic stem cell transplantation with no guidance on management in the published literature. Medical therapy may be considered in selected patients prior to surgical solutions.
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Affiliation(s)
- Zachary Wright
- Hematology/Oncology and Bone Marrow Transplant San Antonio Military Medical Center FT Sam Houston Texas USA
| | | | - John Renshaw
- Hematology/Oncology and Bone Marrow Transplant San Antonio Military Medical Center FT Sam Houston Texas USA
| | - Michael Wiggins
- Hematology/Oncology and Bone Marrow Transplant San Antonio Military Medical Center FT Sam Houston Texas USA
| | - Alexander Brown
- Hematology/Oncology and Bone Marrow Transplant San Antonio Military Medical Center FT Sam Houston Texas USA
| | - Michael Osswald
- Hematology/Oncology and Bone Marrow Transplant San Antonio Military Medical Center FT Sam Houston Texas USA
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Marison SR, Pati B, Laferriere NR, Woo RK, Ha A. Unexpected diagnosis of acute lymphoblastic leukemia in a 2-year-old with acute appendicitis - Case report. Int J Surg Case Rep 2021; 84:106077. [PMID: 34167071 PMCID: PMC8227831 DOI: 10.1016/j.ijscr.2021.106077] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2021] [Revised: 05/26/2021] [Accepted: 06/03/2021] [Indexed: 11/18/2022] Open
Abstract
INTRODUCTION AND IMPORTANCE Appendicitis is an extremely common surgical problem, especially in the pediatric population. However, leukemic infiltration of the appendix is rare and even more so is having acute appendicitis as the initial manifestation. CASE PRESENTATION The patient is a 2-year-old female with multiple febrile illnesses since birth, who presented to the emergency department with a 3-day history of abdominal pain, fever, and decreased appetite. Ultrasound of her right lower quadrant was consistent with acute appendicitis. A laparoscopic appendectomy was performed successfully without complication. However, pathological examination of the specimen revealed an appendix with partial involvement of B-lymphoblastic lymphoma/leukemia in a background of lymphoid hyperplasia. This prompted referral to a pediatric hematologist/oncologist. Further workup revealed abnormal immature cells on peripheral blood flow cytometry. Bone marrow biopsy confirmed a diagnosis of B-cell acute lymphoblastic leukemia. CLINICAL DISCUSSION Though acute appendicitis is very common and management is well documented, it is rare for pathological examination to uncover leukemia as an underlying etiology and to have acute appendicitis as the initial manifestation of hematologic malignancy. To our knowledge, very few similar events have occurred and been documented in the medical literature. CONCLUSION Physicians and surgeons should be aware that, though quite rare, leukemic infiltration of the appendix can occur and should be considered in the differential diagnosis of acute appendicitis. Notably, pathologic examination of the appendix may be particularly informative. Diligent follow-up of abnormal pathology is crucial in cases suggestive of underlying hematologic malignancy.
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Affiliation(s)
- Scott R Marison
- The Queens Medical Center, Department of Surgery, 1356 Lusitana Street, 6th Floor, Honolulu, HI 96813, United States of America.
| | - Brooke Pati
- Tripler Army Medical Center, Department of Surgery, 1 Jarrett White Rd, Honolulu, HI 96859, United States of America
| | - Nicole R Laferriere
- Tripler Army Medical Center, Department of Surgery, 1 Jarrett White Rd, Honolulu, HI 96859, United States of America
| | - Russell K Woo
- Kapiolani Medical Center for Women and Children, Department of Pediatric Surgery, 1319 Punahou St, Honolulu, HI 96826, United States of America
| | - Ally Ha
- Tripler Army Medical Center, Department of Surgery, 1 Jarrett White Rd, Honolulu, HI 96859, United States of America
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Kojima K, Nakamura T, Habiro T, Waraya M, Hayashi K, Ishii KI. Laparoscopic Appendectomy for Acute Appendicitis Complicated by Pancytopenia in Two Patients with Hematologic Diseases. JOURNAL OF THE ANUS RECTUM AND COLON 2021; 5:188-191. [PMID: 33937560 PMCID: PMC8084534 DOI: 10.23922/jarc.2020-077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/06/2020] [Accepted: 12/14/2020] [Indexed: 11/30/2022]
Abstract
A 25-year-old male (Case 1) was waiting for a bone marrow transplant for myelodysplastic syndrome. Due to acute appendicitis, he was advised to undergo gastroenterological surgery. After blood transfusion, he underwent an emergency laparoscopic appendectomy, as no blood cell recovery was expected. The postoperative course was uneventful, and he was discharged. A 71-year-old female (Case 2) developed acute appendicitis during chemotherapy for acute myeloid leukemia (AML). At the time of onset, since her myelosuppression was expected to improve in approximately 1 week, a conservative treatment was administered. However, due to the progression of AML, the expected blood cell recovery did not occur. Therefore, laparoscopic appendectomy was performed 25 days after onset. She was discharged without postoperative adverse events. In cases of acute appendicitis in patients with hematologic disease accompanied by pancytopenia, it is important to establish a careful treatment plan considering the possibility of recovery from myelosuppression and the need to control an intraperitoneal infection in conjunction with a hematologist. Laparoscopic surgery, which is minimally invasive, was an effective surgical procedure.
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Affiliation(s)
- Keita Kojima
- Department of Surgery, Japan Community Health care Organization Sagamino Hospital, Sagamihara, Japan
| | - Takatoshi Nakamura
- Department of Surgery, Japan Community Health care Organization Sagamino Hospital, Sagamihara, Japan.,First Department of Surgery, Dokkyo Medical University, Shimotsuga, Japan
| | - Takeyoshi Habiro
- Department of Surgery, Japan Community Health care Organization Sagamino Hospital, Sagamihara, Japan
| | - Mina Waraya
- Department of Surgery, Japan Community Health care Organization Sagamino Hospital, Sagamihara, Japan
| | - Keiko Hayashi
- Department of Surgery, Japan Community Health care Organization Sagamino Hospital, Sagamihara, Japan
| | - Ken-Ichiro Ishii
- Department of Surgery, Japan Community Health care Organization Sagamino Hospital, Sagamihara, Japan
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Ali A, Alhindi S, Alalwan AA. Acute Appendicitis in a Child With Acute Leukemia and Chemotherapy-Induced Neutropenia: A Case Report and Literature Review. Cureus 2020; 12:e8858. [PMID: 32617245 PMCID: PMC7325351 DOI: 10.7759/cureus.8858] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Acute appendicitis is a rare but important complication in children with leukemia. It can be difficult to diagnose, and it has a complicated disease course, especially in patients receiving chemotherapy. Awareness of these complications is critical, particularly in cases where surgical intervention is required. We report a child with T-cell acute lymphoblastic leukemia and chemotherapy-induced neutropenia who presented with acute appendicitis. He was successfully treated with broad-spectrum empiric antibiotics and a delayed laparoscopic appendectomy.
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Affiliation(s)
- Alaa Ali
- Pediatric Surgery, Salmaniya Medical Complex, Manama, BHR
| | - Saeed Alhindi
- Pediatric Surgery, Salmaniya Medical Complex, Manama, BHR
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Abstract
To study the management of acute appendicitis in neutropenic patients, we retrospectively reviewed cases of acute appendicitis in neutropenic children treated for cancer. The patients' demographics, medical records, and outcomes were tracked. We compared nonoperative treatment versus emergency or delayed surgery. The cases of 30 patients with a mean age of 8.8 years in 12 French departments of Pediatric Hematology/Oncology between 1995 and 2013 were studied. Most patients (90%) were treated for hematological malignancies. Seven of the 30 children were successfully treated with exclusive medical treatment. Early surgery was performed in 6 patients, and the remaining 17 underwent combined management with a first-line antibiotic treatment and delayed appendectomy. Treatments were successful in all cases with transitory complications in only 3 patients. No death linked to infection was reported. Surgery was well tolerated even in the neutropenic period. Appendix perforation was a major risk factor of prolonged hospitalization. Histologic as well as bacteriologic and mycologic/parasitologic analyses were required in case of surgery. Analysis of diagnostic assessments showed the major importance of imaging (ultrasonography and tomography) on diagnosis confirmation. We could not come to a conclusion in the few numbers of reviewed cases because of a significant difference in management strategies, but we can conclude that early surgery after adequate supportive care is an acceptable modality of treatment and must be chosen in the face of life-threatening conditions.
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7
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Fungal Appendicitis in Immunocompromised Children. Indications and Contraindications for Laparoscopic Appendectomy: A Report on 2 Successful Cases. J Pediatr Hematol Oncol 2016; 38:581-4. [PMID: 27164525 DOI: 10.1097/mph.0000000000000563] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
In leukemic patients, appendectomy must be approached with caution because of the increased risk of complications. Fungal appendicitis is rare and only a few cases have been described in the literature, particularly in immunocompromised individuals in whom this infection can be fatal. We present 2 pediatric patients with acute myeloid leukemia, who developed appendicitis during the postchemotherapy neutropenic phase, while receiving antifungal prophylaxis. Fever was the first sign of infection. Laparoscopic appendectomy was performed without postoperative complications. The histologic examination and the culture analysis showed the presence of fungal elements; systemic fungal infection was also excluded. The risk is increased in immunocompromised children with fungal appendicitis and the signs of peritoneal irritation are not always obvious. The histopathologic demonstration of fungal elements and tissue reaction is mandatory for a definitive diagnosis. Laparoscopic appendectomy should be considered as the gold standard procedure to avoid fungal dissemination. Moreover, laparoscopic surgery and its inherent mini-invasive surgical advantages may improve the overall survival without incurring significant complications.
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Singer J, Stringel G, Ozkaynak MF, McBride W, Pandya S, Sandoval C. Laparoscopic Surgery for Acute Appendicitis in Children With Cancer. JSLS 2016; 19. [PMID: 26390529 PMCID: PMC4558416 DOI: 10.4293/jsls.2015.00066] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
INTRODUCTION Abdominal pain during cancer chemotherapy may be caused by medical or surgical conditions. A retrospective review of 5 children with cancer who had appendicitis while receiving chemotherapy was performed. CASE DESCRIPTIONS Three had acute lymphoblastic leukemia,and 1 each had T-cell lymphoblastic lymphoma and rhabdomyosarcoma. Two of the patients had a Pediatric Appendectomy Score of 6, and 1 each had a score of 7, 5, and 2. All had evidence of appendicitis on computed tomography. Laparoscopic appendectomy was performed without any perioperative complication. DISCUSSION Appendicitis is an important diagnosis in children with cancer, and laparoscopic appendectomy is safe and the procedure of choice.
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Wong CWY, Chung PHY, Lan LCL, Wong KKY. Acute appendicitis presenting as pneumoperitoneum in a teenage boy undergoing chemotherapy. BMJ Case Rep 2015; 2015:bcr-2015-210347. [PMID: 26443090 DOI: 10.1136/bcr-2015-210347] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Chemotherapy of paediatric haematological malignancies can induce infectious complications of the gastrointestinal tract, with predilection of the ileocaecal region. Common causes of right lower abdominal pain in the febrile patient with neutropaenia include acute appendicitis, typhlitis, ileus and intussusception. In this case report, we describe a teenage boy with acute appendicitis presenting with pneumoperitoneum during his course of chemotherapy. The incidence, aetiology, diagnosis, investigations and management of this uncommon presentation in a common disease are discussed. The controversial topic of the management of acute appendicitis in a febrile patient with neutropaenia is also reviewed and discussed.
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Affiliation(s)
- C W Y Wong
- Division of Paediatric Surgery, Department of Surgery, Queen Mary Hospital, The University of Hong Kong, Hong Kong, Hong Kong
| | - P H Y Chung
- Division of Paediatric Surgery, Department of Surgery, Queen Mary Hospital, The University of Hong Kong, Hong Kong, Hong Kong
| | - L C L Lan
- Division of Paediatric Surgery, Department of Surgery, Queen Mary Hospital, The University of Hong Kong, Hong Kong, Hong Kong
| | - K K Y Wong
- Division of Paediatric Surgery, Department of Surgery, Queen Mary Hospital, The University of Hong Kong, Hong Kong, Hong Kong
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10
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Kim Y, Moon SB. Acute intestinal obstruction requiring surgery in pediatric malignancies: Summary of 7 cases. JOURNAL OF PEDIATRIC SURGERY CASE REPORTS 2015. [DOI: 10.1016/j.epsc.2015.05.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
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11
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Acute appendicitis in acute leukemia and the potential role of decitabine in the critically ill patient. Leuk Res Rep 2015; 4:21-3. [PMID: 25870788 PMCID: PMC4392291 DOI: 10.1016/j.lrr.2015.03.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2014] [Revised: 01/29/2015] [Accepted: 03/03/2015] [Indexed: 11/21/2022] Open
Abstract
Acute appendicitis in children with acute leukemia is uncommon and often recognized late. Immunocompromised host state coupled with the importance of avoiding treatment delays makes management additionally challenging. Leukemic infiltration of the appendix though rare must also be considered. Although successful conservative management has been reported, surgical intervention is required in most cases. We present our experience with acute appendicitis in children with acute leukemia and a case of complete remission of acute myeloid leukemia with a short course of decitabine. Decitabine may serve as bridging therapy in critically ill patients who are unable to undergo intensive chemotherapy.
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12
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Meralgia Paresthetica as a Presentation of Acute Appendicitis in a Girl With Acute Lymphoblastic Leukemia. J Pediatr Hematol Oncol 2015; 37:e182-3. [PMID: 24942034 DOI: 10.1097/mph.0000000000000189] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
A 7-year-old girl with Philadelphia chromosome-positive acute lymphoblastic leukemia developed recurrent fever and meralgia paresthetica (MP) during chemotherapy, which resolved after administration of antibiotics. Five months after the onset of these symptoms, enhanced computed tomography showed a periappendiceal abscess extending into the psoas muscle. The cause of her fever and MP was thought to be appendicitis, which probably developed during induction chemotherapy but did not result in typical abdominal pain. Patients with recurrent fever and MP should be evaluated by imaging examinations including computed tomography to search for appendicitis.
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13
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McAteer JP, Sanchez SE, Rutledge JC, Waldhausen JHT. Isolated appendiceal typhlitis masquerading as perforated appendicitis in the setting of acute lymphoblastic leukemia. Pediatr Surg Int 2014; 30:561-4. [PMID: 24448913 DOI: 10.1007/s00383-014-3473-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/09/2014] [Indexed: 02/08/2023]
Abstract
Abdominal pain is common during chemotherapy for childhood leukemia. Clinically differentiating typhlitis from appendicitis can be difficult. We present an 8-year-old boy with abdominal pain in the setting of acute lymphoblastic leukemia and neutropenia. Following appendectomy for presumed appendicitis, pathology revealed appendiceal typhlitis. Diagnostic and treatment considerations are discussed.
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Affiliation(s)
- Jarod P McAteer
- Division of Pediatric General and Thoracic Surgery, Department of Surgery, Seattle Children's Hospital and University of Washington, 4800 Sand Point Way NE, Seattle, WA, 98105, USA,
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14
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Kontoyiannis DP, Mathur M, Chen YB, Shellito PC, Tse JY. Case records of the Massachusetts General Hospital. Case 13-2014. A 41-year-old man with fever and abdominal pain after stem-cell transplantation. N Engl J Med 2014; 370:1637-46. [PMID: 24758620 DOI: 10.1056/nejmcpc1305994] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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15
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Appendectomy in Neutropenic Children: A Safe and Expedient Solution to a Challenging Problem. J Surg Res 2012; 178:110-2. [PMID: 21777928 DOI: 10.1016/j.jss.2011.05.065] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2011] [Revised: 05/23/2011] [Accepted: 05/23/2012] [Indexed: 11/22/2022]
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16
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Kim EY, Lee JW, Chung NG, Cho B, Kim HK, Chung JH. Acute appendicitis in children with acute leukemia: experiences of a single institution in Korea. Yonsei Med J 2012; 53:781-7. [PMID: 22665346 PMCID: PMC3381485 DOI: 10.3349/ymj.2012.53.4.781] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
PURPOSE Acute appendicitis has been reported to be relatively rare in pediatric leukemia patients but there is no official data for this in Korea. And there is no consensus for its treatment in this population. MATERIALS AND METHODS We conducted a retrospective study of 7 patients diagnosed with appendicitis among 1209 pediatric patients who were diagnosed with leukemia from 1996 to 2008 at a single institution in Korea. RESULTS The median age at the time of the diagnosis of appendicitis was 12 years (range: 3-15 years), and 3 of the patients were male. The median absolute neutrophil count (ANC) at the time of diagnosis was 0.99×10⁹/L (range: 0-3×10⁹/L). The mean time from the onset of symptoms to the diagnosis was 4 days. All 7 leukemia patients with appendicitis underwent surgery and they demonstrated a survival of 100% without significant complications. CONCLUSION The incidence of appendicitis in pediatric leukemia patients was 0.57% in our study. Early diagnosis with abdominal ultrasound or computed tomography and early surgical resection in leukemic patient with acute appendicitis may be a safer and more effective treatment option. Even when perforation has already occurred and when the patient has an ANC of 0×10⁹/L, surgical treatment may improve overall survival without incurring significant complications.
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Affiliation(s)
- Eun Young Kim
- Department of Surgery, Yeouido St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Jae Wook Lee
- Department of Pediatrics, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Nak-Gyun Chung
- Department of Pediatrics, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Bin Cho
- Department of Pediatrics, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Hack-Ki Kim
- Department of Pediatrics, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Jae Hee Chung
- Department of Surgery, Yeouido St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
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Abstract
Gastrointestinal (GI) manifestations of leukemia occur in up to 25% of patients at autopsy, generally during relapse. Its presence varies with the type of leukemia and has been decreasing over time due to improved chemotherapy. Gross leukemic lesions are most common in the stomach, ileum, and proximal colon. Leukemia in the esophagus and stomach includes hemorrhagic lesions from petechiae to ulcers, leukemic infiltrates, pseudomembranous esophagitis, and fungal esophagitis. Lesions in the small and large bowel are usually hemorrhagic or infiltrative. Infiltration of lymphoreticular organs, mainly spleen, liver, and lymph nodes, is more prominent in chronic than acute leukemia. Neutropenic enterocolitis, a necrotizing process involving the cecum, ascending colon, and terminal ileum, is increasing in incidence due to greater intensity of chemotherapy. Distension of bowel leads to mucosal breaches, permitting entry of organisms that grow profusely in the absence of neutrophils. Ischemic necrosis follows, leading to perforation and/or peritonitis. Patients present with fever, abdominal pain, diarrhea, nausea, vomiting, abdominal distension and tenderness. Ultrasound and computed tomography scans show thickening of the bowel wall. Treatment is supportive with surgery for necrosis and perforation. The main GI causes of death in leukemia are hemorrhage, infection, and necrotizing enterocolitis.
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Affiliation(s)
- Ellen C Ebert
- Department of Medicine, UMDNJ-Robert Wood Johnson Medical School, New Brunswick, NJ, USA.
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Gray TLV, Ooi CY, Tran D, Traubici J, Gerstle JT, Sung L. Gastrointestinal complications in children with acute myeloid leukemia. Leuk Lymphoma 2010; 51:768-77. [PMID: 20350277 DOI: 10.3109/10428191003695652] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Gastrointestinal complications in pediatric acute myeloid leukemia (AML) have not been systematically described in the literature. Our objective was to describe complications related to the small and large bowel in children with AML. Literature searches were conducted of Ovid Medline from 1950 to November 2009 and EMBASE from 1980 to November 2009. We included any study design that described gastrointestinal complications in children and/or adults with AML. Common gastrointestinal complications were typhlitis and enterocolitis. Less common complications included appendicitis, pneumatosis intestinalis, and perianal infections. Both leukemia infiltration and intensive chemotherapy likely play a role in the etiology of these conditions. There is a paucity of carefully conducted studies that describe the natural history of typhlitis and enterocolitis and evidence is needed to help guide the management of gastrointestinal complications. Gastrointestinal complications are relatively common in children with AML. Conduction of carefully performed cohort studies is needed to better understand the spectrum of symptoms and expected consequences of gastrointestinal complications. Randomized trials are required to develop evidence-based guidelines for the management of gastrointestinal complications in pediatric AML.
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Affiliation(s)
- Tyler L V Gray
- Division of Haematology/Oncology, The Hospital for Sick Children, 555 University Avenue, Toronto, Ontario, Canada M5G1X8
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19
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Acute appendicitis in adult neutropenic patients with hematologic malignancies. Bone Marrow Transplant 2008; 42:701-3. [PMID: 18679367 DOI: 10.1038/bmt.2008.235] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Chui CH, Chan MY, Tan AM, Low Y, Yap TL, Jacobsen AS. Appendicitis in immunosuppressed children: Still a diagnostic and therapeutic dilemma? Pediatr Blood Cancer 2008; 50:1282-3. [PMID: 18306278 DOI: 10.1002/pbc.21554] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
Acute appendicitis in the immunosuppressed patients are often difficult to diagnose and are associated with increased morbidity and mortality. Recent debates on primary appendicitis and typhlitis-associated appendicitis have contributed to the diagnostic and therapeutic dilemma. We retrospectively reviewed all our immunosuppressed patients with appendicitis. The most frequent presenting symptom was fever followed by non-specific intermittent abdominal pain. The median delay in diagnosis was 4 days. CT scan was useful in making the diagnosis, but the presence of adjacent bowel thickening has contributed to the dilemma in diagnosis and treatment.
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Affiliation(s)
- Chan-Hon Chui
- Department of Pediatric Surgery, KK Women's and Children's Hospital, Singapore, Singapore.
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21
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Conservative management of acute appendicitis in children with hematologic malignancies during chemotherapy-induced neutropenia. J Pediatr Hematol Oncol 2008; 30:464-7. [PMID: 18525466 DOI: 10.1097/mph.0b013e318168e7cb] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
The management of acute appendicitis in the febrile neutropenic patient after intensive chemotherapy is controversial. We report our single-center-experience of 5 children diagnosed with appendicitis during febrile neutropenia after chemotherapy for acute leukemia or lymphoma. All patients presented with an isolated appendicitis without signs of overt mucositis or more diffuse enterocolitis. The clinical diagnosis was confirmed by ultrasonography. Perforation with retrocecal abscess was present in 1 patient. Administration of combination antimicrobial regimens including meropenem resulted in complete resolution in all patients. Our observations indicate that acute appendicitis in clinically stable neutropenic cancer patients can be managed conservatively without surgery.
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Alioglu B, Avci Z, Ozcay F, Arda S, Ozbek N. Neutropenic enterocolitis in children with acute leukemia or aplastic anemia. Int J Hematol 2008; 86:364-8. [PMID: 18055346 DOI: 10.1532/ijh97.e0739] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Neutropenic enterocolitis (NE) and acute appendicitis are life-threatening conditions that develop in children with severe or prolonged neutropenia secondary to acute leukemia and lymphoma. The medical records of 118 patients who were treated for acute lymphoblastic leukemia (69 patients), acute myelogenous leukemia (22 patients), or aplastic anemia (27 patients) between 1997 and 2006 in our hospital pediatric hematology department were examined retrospectively. NE was diagnosed in 11 patients (age range, 2.5-16 years) on the basis of clinical and laboratory features. Two of these 11 patients had appendicitis in addition to NE. Conservative treatment was favored for all patients, but 1 patient with acute appendicitis underwent surgery. Neutropenic patients with a hematologic malignancy and abdominal pain should receive their diagnoses immediately and undergo treatment. NE and acute appendicitis should always be considered in the differential diagnosis of abdominal pain. Conservative treatment must be chosen initially for patients with NE, and these patients should be evaluated carefully for surgery. The criteria for the surgical process are the same as those for immunocompetent children. In addition, the close monitoring of hematologic factors is necessary.
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Affiliation(s)
- Bulent Alioglu
- Department of Pediatric Hematology, Baskent University Faculty of Medicine, Baskent University, Ankara, Turkey.
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AL-ANAZI KA, AL-JASSER AM, EVANS DAP, DAFF NA. Outcome of surgery in patients with hematological malignancies: A 12-year retrospective analysis. Asia Pac J Clin Oncol 2006. [DOI: 10.1111/j.1743-7563.2006.00049.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Ozyurek E, Arda S, Ozkiraz S, Alioglu B, Arikan U, Ozbek N. Febrile neutropenia as the presenting sign of appendicitis in an adolescent with acute myelogenous leukemia. Pediatr Hematol Oncol 2006; 23:269-73. [PMID: 16517543 DOI: 10.1080/08880010500506735] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
The diagnosis and management of a surgical abdomen in patients with acute leukemia is quite difficult because of the complications and treatment of disease itself. A 13-year-old boy with acute myelogenous leukemia developed 2 episodes of febrile neutropenia during induction therapy. The second one was treated with a 5-day course of parenteral antimicrobial therapy, but the patient then presented with right lower quadrant abdominal tenderness, guarding, and rebound tenderness. Abdominal ultrasonography and computed tomography revealed appendicitis. Conservative medical management was unsuccessful, and appendectomy was performed 5 days after appendicitis was diagnosed. The patient's clinical manifestations resolved 5 days later. The case illustrates that fever may be the first manifestation of appendicitis in a child with acute myelogenous leukaemia who is neutropenic. Surgery is acceptable as first-line treatment in such cases.
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Affiliation(s)
- Emel Ozyurek
- Baskent University Faculty of 0Medicine, Department of Haematology, Ankara, Turkey
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Palomino-Portilla EA, Valbuena JR, Quinones-Avila MDP, Medeiros LJ. Myeloid sarcoma of appendix mimicking acute appendicitis. Arch Pathol Lab Med 2005; 129:1027-31. [PMID: 16048393 DOI: 10.5858/2005-129-1027-msoama] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
CONTEXT Myeloid sarcoma is a neoplasm of immature myeloid cells involving an extramedullary anatomic site that is usually, although not always, associated with acute myeloid leukemia. Any extramedullary site can be involved by myeloid sarcoma, but involvement of the cecal appendix is uncommon, and symptoms mimicking acute appendicitis as a result of appendiceal involvement are rare. OBJECTIVE To describe the clinicopathologic features of 2 patients with myeloid sarcoma involving the appendix who presented with right lower quadrant pain suggestive of acute appendicitis and prompting appendectomy. DESIGN Clinical information for both patients was obtained from the medical record. Routine hematoxylin-eosin-stained slides, naphthol-ASD-chloroacetate stain, and immunohistochemical stains for myeloid, B-cell, and T-cell antigens were prepared. RESULTS Peripheral blood and bone marrow were infiltrated by coexistent acute myeloid leukemia in case 1 but were negative for leukemia in case 2. In case 2, the patient had a history of acute myeloid leukemia that had been treated by an allogenic bone marrow transplant 7 months earlier. Histologic examination of the appendix revealed poorly differentiated myeloid sarcoma in both cases. Each neoplasm was positive for chloroacetate esterase, myeloperoxidase, lysozyme, and CD43 and was negative for CD3 and CD20. CONCLUSIONS Myeloid sarcoma involving the appendix can rarely cause pain or other symptoms mimicking acute appendicitis. A high index of suspicion combined with the use of cytochemical and immunohistochemical studies are helpful in establishing the diagnosis.
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Hobson MJ, Carney DE, Molik KA, Vik T, Scherer LRT, Rouse TM, West KW, Grosfeld JL, Billmire DF. Appendicitis in childhood hematologic malignancies: analysis and comparison with typhilitis. J Pediatr Surg 2005; 40:214-9; discussion 219-20. [PMID: 15871157 DOI: 10.1016/j.jpedsurg.2004.09.048] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
BACKGROUND/PURPOSE Recognition of appendicitis in the child with hematologic malignancy may be difficult particularly in the setting of neutropenia and multiple medications causing an altered inflammatory response. Typhilitis may produce a similar constellation of clinical findings causing further diagnostic confusion. This review compares the relative frequency of these two conditions in children with hematologic malignancy with a focus on the clinical presentation, distinguishing features, surgical management, and outcome for patients with appendicitis. METHODS This institutional review board-approved retrospective study evaluated 464 pediatric patients treated for hematologic malignancy at our institution from 1997 to 2003. From this cohort, we identified all children with a diagnosis of appendicitis or typhilitis. Data include demographics, clinical presentation, laboratory studies, and computed tomography (CT) scan findings. Groups were compared using the Fisher exact test. Significance was defined as P < .05. RESULTS Eight (1.7%) of 464 children were diagnosed with typhilitis and 7 (1.5%) with appendicitis. There were no demographic differences between patients with appendicitis and typhilitis. Distinguishing clinical features in children with typhilitis included presence of fever and diarrhea. Clinical presentation in children with appendicitis was atypical in 5 of 7 cases yielding an incorrect preoperative diagnosis in all 5. Radiographic evaluation by CT scan accurately defined typhilitis, but not appendicitis. An operation was performed on all 7 children with appendicitis with no operative morbidity or mortality. CONCLUSIONS Appendicitis and typhilitis occur with similar frequency in children with leukemia and lymphoma. Typhilitis is accurately diagnosed with clinical findings of fever, diarrhea, abdominal pain, and typical CT scan findings. Appendicitis tends to present with atypical findings, but can be successfully managed with standard surgical care.
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Affiliation(s)
- Michael J Hobson
- Section of Pediatric Surgery, Department of Surgery, Indiana University School of Medicine and the J.W. Riley Hospital for Children, Indianapolis, IN, USA
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Turrini O, Moutardier V, Vey N, Guiramand J, Lelong B, Delpero JR. Sometimes appendicitis can wait. Am J Hematol 2004; 76:312-3. [PMID: 15224379 DOI: 10.1002/ajh.20086] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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Affiliation(s)
- Steven D Miller
- Department of Surgery, University of Texas Medical School at Houston, Houston, TX, USA
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Schlatter M, Snyder K, Freyer D. Successful nonoperative management of typhlitis in pediatric oncology patients. J Pediatr Surg 2002; 37:1151-5. [PMID: 12149691 DOI: 10.1053/jpsu.2002.34461] [Citation(s) in RCA: 50] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND/PURPOSE The optimal management for typhlitis in pediatric oncology patients has not always been clear from the medical literature. Trends have varied between operative and nonoperative approaches. The aim of this study was to review the successful nonoperative management of these patients at our institution over the last decade to further clarify management guidelines for this difficult problem. METHODS Medical records of pediatric hematology and oncology patients up to 21 years of age with typhlitis diagnosed at the DeVos Children's Hospital from 1990 to 2000 were reviewed. RESULTS Twelve patients were included. Ten patients (83%) with computed tomography (CT) scans suggestive of the diagnosis were treated successfully nonoperatively. Management usually included bowel rest, antibiotics, and supplemental parenteral nutrition. Two patients (17%) in whom CT scans were not obtained underwent surgery for presumed appendicitis and pneumoperitoneum, respectively. Typhlitis was found incidentally. In the latter patient, the pneumoperitoneum resulted from a perforated jejunum caused by graft-versus-host disease. This patient died of septic complications and was the only mortality in the series (8%). CONCLUSIONS Pediatric cancer patients with typhlitis can be treated carefully nonoperatively with bowel rest, antibiotics, and supplemental nutrition. Usual indications for surgery (ie, perforation, clinical deterioration) still should be used. The early use of CT scanning helps to facilitate the diagnosis and may provide the ability to differentiate typhlitis from other abdominal diseases for which surgery would be indicated.
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Affiliation(s)
- Marc Schlatter
- Department of Pediatric Surgery, DeVos Children's Hospital, Grand Rapids, MI, USA
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Abdul Wahid FBS, Keng CS, Ali RBA. Acute leukaemia masquerading as acute abdomen. HOSPITAL MEDICINE (LONDON, ENGLAND : 1998) 2002; 63:372-3. [PMID: 12096671 DOI: 10.12968/hosp.2002.63.6.2011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
This article reports three patients with acute leukaemia who presented with acute abdomen as the first manifestation of the disease. Leukaemic infiltrates of the bowel and appendix may have caused the abdominal symptoms in these patients. Acute leukaemia should be included in the differential diagnosis of severe abdominal pain associated with an abnormal blood count. This report highlights the importance of early diagnosis of acute leukaemia as initiation of cytotoxic chemotherapy results in prompt resolution of the abdominal catastrophe and obviates the need for surgery.
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Affiliation(s)
- Fadilah binti S Abdul Wahid
- Division of Haematology and Stem Cell Transplantation, MAKNA Hospital Universiti Kebangsaan Malaysia Cancer Institute, Kuala Lumpur, Malaysia.
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Pastore D, Specchia G, Mele G, Montagna MT, Margari A, Carluccio P, Nacchiero M, Liso V. Typhlitis complicating induction therapy in adult acute myeloid leukemia. Leuk Lymphoma 2002; 43:911-4. [PMID: 12153186 DOI: 10.1080/10428190290017105] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
In a retrospective analysis of 161 consecutive adult patients with de novo acute myeloid leukemia undergoing induction therapy, including cytarabine, etoposide and anthracyclines, seven patients (4.3%) developed typhlitis. All presented severe neutropenia, fever, abdominal pain and tenderness within 16 days from starting chemotherapy (median 11 days; range 5-16). Three patients underwent surgery and survived, four were treated only with supportive therapy: two recovered and two died. In our experience early recognition of typhlitis and rapid recovery of the neutrophils are the most important determinants of the results of surgical and/or medical approaches. The management of typhlitis, a life-threatening condition, is controversial and depends on many factors characterizing each patient, which must be evaluated in collaboration between the surgeon and the hematologist.
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Affiliation(s)
- D Pastore
- Department of Medicine-DIMIMP Hematology, University of Bari, Italy
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Yahanda AM. Surgical Emergencies in the Cancer Patient. Surgery 2001. [DOI: 10.1007/978-3-642-57282-1_83] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
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Sbragia Neto L, Oliveira-Filho AG, Epelman S, Koeller HF, Bustorff-Silva JM, Brandalise SR. Selective surgical indication in the management of neutropenic children presenting with acute abdomen. Pediatr Hematol Oncol 2000; 17:483-7. [PMID: 10989469 DOI: 10.1080/08880010050120845] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
As the treatment of pediatric malignancies improves and survival increases, the diagnosis of acute abdomen in these patients also becomes more common. Nevertheless, the management of this condition is still controversial. The authors report their experience in treating 12 neutropenic children with acute abdomen. The charts of 12 neutropenic patients with a diagnosis of acute abdomen treated at Boldrini Children's Cancer Center in Campinas, Brazil, between 1991 and 1996, were reviewed. Therapeutic strategy included an initial period of bowel rest, general supportive measures, and broad-spectrum antibiotics while waiting for the neutrophil count to rise. Three patients recovered completely without surgery, 8 underwent late surgery without complications, and 1 died due to uncontrolled sepsis before surgery. The treatment of acute abdomen in neutropenic children remains controversial. As shown in the present series, an initial nonoperative approach with selective surgical indication appears to be safe and to yield good results. Supportive treatment, until the neutrophil count rises, followed by surgery, if necessary, appears to be a sound therapeutic approach for neutropenic children with acute abdomen.
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Affiliation(s)
- L Sbragia Neto
- Department of Pediatric Surgery, University of Campinas, São Paulo, Brazil
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Abstract
The advent of aggressive treatment protocols and the development of new techniques and procedures now require that the pediatric surgeon be an integral part of all aspects of pediatric oncology care. Supportive care issues, rather than primary tumor management decisions, now dominate the pediatric surgeon's experience and range from managing the different types of vascular access devices and their complications to assessing the surgical implications of the toxic complications of current chemotherapy protocols. New treatments such as bone marrow transplantation have presented new challenges to the pediatric surgeon, while new techniques such as minimally invasive surgery have dramatically improved our ability to render compassionate and more effective care to our patients as they undergo these potentially toxic treatment regimens.
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Affiliation(s)
- P W Dillon
- Section of Pediatric Surgery, Penn State Geisinger Children's Hospital, Hershey, Pennsylvania, USA.
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Abstract
A complete understanding of the anatomy, pathophysiology, and presenting signs and symptoms of appendicitis, combined with a thorough history and physical examination, will be the most important factors in allowing the practicing emergency physician to make the correct diagnosis of acute appendicitis. For patients in which the diagnosis is less clear or for patients in high-risk groups (extremes of age, pregnant women, and immunocompromised patients) additional diagnostic testing, usually US or CT, and early surgical consultation are recommended.
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Affiliation(s)
- C S Graffeo
- Department of Emergency Medicine, Eastern Virginia Medical School, Norfolk, USA
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Abstract
We report a family with autosomal dominant inherited neutropenia, characterized by maturation arrest of neutrophil precursors and hypergammaglobulinaemia. A mother, two children by her first marriage and two by her second were affected. They suffered recurrent lung, skin, ear and periodontal infections. Four have had appendicitis, and three mastoiditis. One died at 7 years from neutropenic enterocolitis, and a second at 10 years from small bowel infarction. Four who were treated with rhG-CSF responded to 5-14 micrograms/kg/day with normal neutrophil counts. Daily therapy has maintained neutrophil counts above 1000 x 10(9) per litre. Elective appendicectomy and long term G-CSF therapy are indicated.
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Affiliation(s)
- G L Briars
- Department of Paediatrics, East Glamorgan General Hospital, Mid-Glamorgan, U.K
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Gilad E, Paret G, Katz M, Vardi A, Kennet G, Barzilay Z. Plain radiography for diagnosis of gastrointestinal perforation in immune-compromised children--is it enough? MEDICAL AND PEDIATRIC ONCOLOGY 1995; 25:470-2. [PMID: 7565310 DOI: 10.1002/mpo.2950250609] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
Gastrointestinal perforation is a surgical emergency in the pediatric patient and any delay in diagnosis might be hazardous. In immunocompromised children, the clinical signs of perforation may be blunted. We describe a child with acute lymphoblastic leukemia (ALL) and a perforated appendix and ileum in whom computerized tomography (CT) revealed extraluminal air that was not initially identified on plain abdominal film. Our case demonstrates the importance of early abdominal CT and ultrasound examination in detecting these potentially lethal complications.
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Affiliation(s)
- E Gilad
- Division of Pediatrics, Chaim Sheba Medical Center, Tel Hashomer, Israel
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Zaki AM, MacMahon RA, Gray AR. Acute appendicitis in children: when does ultrasound help? THE AUSTRALIAN AND NEW ZEALAND JOURNAL OF SURGERY 1994; 64:695-8. [PMID: 7945068 DOI: 10.1111/j.1445-2197.1994.tb02060.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Fifty-six patients with possible appendicitis were evaluated clinically and by ultrasound. Ultrasound examination visualized the appendix in 18 of the patients evaluated and showed another pathology in six others. It was useful when the clinical picture was not clear (25 patients) as it showed an inflamed appendix in 10 patients. This was of particular value when there was another critical illness making clinical evaluation difficult (three patients), and for the diagnosis of other unsuspected pathological conditions (six patients). It did not affect the line of management when the clinical picture was clear enough to diagnose or exclude acute appendicitis.
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Affiliation(s)
- A M Zaki
- Department of Pediatric Surgery, Monash Medical Centre, Clayton, Victoria, Australia
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Media Review: References of Interest for the Pediatric Oncology Nurse. J Pediatr Oncol Nurs 1992. [DOI: 10.1177/104345429200900410] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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