Right lower quadrant pain in the immunocompromised patient: CT findings in 10 cases

Ileocolic Intussusception in a Leukemic Adult Patient: A Case Report and Review of the Literature

We present a rare case of intussusception in a 41-year-old man with acute myeloid leukemia without an evidence of leukemic infiltration of the bowel. The patient presented to the emergency room with right lower quadrant pain. Initially he was diagnosed with typhlitis. CT scan was done and showed ileocolic intussusception without a definitive lead point identified. Patient underwent hemicolectomy and histopathological study of the specimen did not show any leukemic infiltrate. High suspicion of intussusception should be kept in mind with leukemic patients presenting with abdominal pain.

Isolated appendiceal typhlitis masquerading as perforated appendicitis in the setting of acute lymphoblastic leukemia

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.

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

Background:

Diarrhea is a frequent complication in children with cancer who received intensive chemotheraputic regimens. It may be caused by several factors, neutropenic enterocolitis (NE) being the most serious.

Aim:

To study diarrhea in neutropenic cancer patients in the pediatric age group, with its underlying etiologies and risk factors, especially the bacterial causes, with special concern on NE.

Materials and Methods:

This study was carried out at the Pediatric Hematology and Oncology Units, Zagazig University Hospitals, Egypt, from January 2009 to September 2010. All children with malignant diseases who are ≤12 years of age were included. Patients who were neutropenic (<500/ mm³) on admission or who became neutropenic during their stay in the hospital were monitored regularly (daily) for diarrhea. Neutropenic cancer patients with diarrhea were grouped into two groups: Group 1, with NE, and group 2, with neutropenic diarrhea rather than NE. On the first day of diarrhea, patients were subjected to complete blood count, blood cultures, stool microscopy and culture. Abdominal ultrasonography was carried out within 3 days of diarrhea.

Results:

A total of 200 children ≤12 years old, suffering from different malignancies, with a total of 180 neutropenic episodes were followed. Diarrhea was observed in 100 episodes (55.5%). NE constituted 16% of these diarrheal episodes. All patients with NE had significantly more severe neutropenia, and this was of longer duration than the other group. All patients with NE were febrile, with 100% positive blood culture. Stool analysis diagnosed giardiasis in 4.8% of the non-NE patients and in none of the NE patients, while stool culture was positive in 75% of the NE patients compared with 40.5% of the other group.

Conclusions:

Diarrhea is a common complication in neutropenic cancer children. Gram negative bacteria and Candida are the most incriminated pathogens. Duration and severity of neutropenia carry a great risk for the development of NE.

Beyond appendicitis: common and uncommon gastrointestinal causes of right lower quadrant abdominal pain at multidetector CT

Right lower quadrant abdominal pain is one of the most common causes of a patient visit to the emergency department. Although appendicitis is the most common condition requiring surgery in patients with abdominal pain, right lower quadrant pain can be indicative of a vast list of differential diagnoses and is thus a challenge for clinicians. Other causes of right lower quadrant pain beyond appendicitis include inflammatory and infectious conditions involving the ileocecal region; diverticulitis; malignancies; conditions affecting the epiploic appendages, omentum, and mesentery; and miscellaneous conditions. Multidetector computed tomography (CT) has emerged as the modality of choice for evaluation of patients with several acute traumatic and nontraumatic conditions causing right lower quadrant pain. Multidetector CT is an extremely useful noninvasive method for diagnosis and management of not only the most common causes such as appendicitis but also less common conditions.

Gastrointestinal complications in children with acute myeloid leukemia

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.

CT imaging of colitis

Computed tomography (CT) is widely used to assess patients with nonspecific abdominal pain or who are suspected of having colitis. The authors recommend multidetector CT with oral, rectal, and intravenous contrast material and thin sections, which can accurately demonstrate inflammatory changes in the colonic wall and help assess the extent of disease. In most cases, the final diagnosis of the type of colitis is based on clinical and laboratory data and colonoscopic and biopsy findings, but specific CT features help narrow the differential diagnosis. Ulcerative colitis is distinguished from granulomatous colitis (Crohn disease) in terms of location of involvement, extent and appearance of colonic wall thickening, and type of complications. Ulcerative colitis and Crohn disease (granulomatous colitis) are rarely associated with ascites, which is often seen in infectious, ischemic, and pseudomembranous colitis. Pseudomembranous colitis also demonstrates marked wall thickening and, occasionally, skip areas but is associated with broad-spectrum antibiotic treatment or chemotherapy. Neutropenic colitis is characterized by right-sided colonic and ileal involvement, whereas ischemic colitis is characterized by vascular distribution pattern and history. Diverticulitis is a focal asymmetric process with fascial thickening and inflamed diverticula. Dilatation of a thick-walled appendix with increased enhancement and adjacent stranding suggests appendicitis, but inflammatory changes may extend to the cecum and terminal ileum. Epiploic appendagitis is a focal rim-enhancing area next to the colon, usually without any substantial colonic wall thickening.

Typhlitis in childhood cancer

BACKGROUND

Typhlitis is increasingly recognized in children undergoing chemotherapy but is poorly characterized. The authors investigated the demographic, clinical, and imaging (ultrasonography and computed tomography [CT] scans) variables related to the diagnosis, risk, and outcome of typhlitis.

METHODS

The authors reviewed the records of patients who had typhlitis (bowel wall thickness > or = 0.3 cm plus clinical findings) during treatment at St. Jude Children's Research Hospital (Memphis, TN) between 1990 and 2001. They assessed whether duration of typhlitis was related to bowel wall thickness, extent of colonic involvement, ascites, demographics, primary diagnosis, symptoms of typhlitis, or duration of neutropenia. To identify risk factors for typhlitis, the authors compared the demographic data and previous drug therapy of 78 patients who had typhlitis and 1231 identically treated children who did not.

RESULTS

Of 3171 children, 83 (2.6%) developed typhlitis. Frequent symptoms were abdominal pain (91%), fever (84%), abdominal tenderness (82%), and diarrhea (72%). Twelve percent of the patients were not neutropenic. Duration of typhlitis was associated with bowel wall thickness measured by ultrasonography (n = 68; P = 0.05) but not CT scan (n = 48; P = 0.67) and was associated with duration of neutropenia (P = 0.02), fever (P = 0.01), and abdominal tenderness (P = 0.04). Age >16 years at cancer diagnosis was the only demographic factor associated with typhlitis (P = 0.03). Two patients died of typhlitis.

CONCLUSIONS

Ultrasonography was a useful imaging modality for children with suspected typhlitis. The classic triad of abdominal pain, fever, and neutropenia may be absent. The severity of typhlitis was related to the duration of neutropenia and the presence of fever or abdominal tenderness.

Neutropenic enterocolitis in adults: systematic analysis of evidence quality

OBJECTIVE

Neutropenic enterocolitis is a life-threatening complication occurring most frequently after intensive chemotherapy in acute leukaemias. The literature is heterogeneous and a systematic review is lacking.

METHODS

Following a systematic search we categorised all relevant reports according to their quality and extracted evidence to answer the questions: Which diagnostic criteria are appropriate? What is the incidence of neutropenic enterocolitis? Are there good quality studies supporting specific interventions: Which empiric antimicrobial therapy is recommendable? Is neutropenic enterocolitis without surgical emergency complications an indication for bowel resection?

RESULTS

We found and analysed 145 articles of these reports: 64 were reports of single cases, 30 papers reported of two or three cases, 13 were narrative reviews, 34 were retrospective case series of more than three cases and four were prospective diagnostic studies. There were no prospective trials or case control studies on the therapy of neutropenic enterocolitis. There was no consensus on diagnostic criteria. We discuss the difficulty to define diagnostic criteria without having a disease definition. Histology is mostly not available in the living patients. We suggest applying a combination of clinical and radiological criteria: fever, abdominal pain and any bowel wall thickening >4 mm detected by ultrasonography (US) or computed tomography. We calculated a pooled incidence rate from 21 studies of 5.3% (266/5058; 95% CI: 4.7%-5.9%) in patients hospitalised for haematological malignancies, for high-dose chemotherapy in solid tumours or for aplastic anaemia.

CONCLUSIONS

This systematic review provides diagnostic criteria for neutropenic enterocolitis, presents a quantitative synthesis on its incidence and discusses its treatment recommendations. Prospective studies are clearly warranted.

Pancolitis associated with docetaxel: a rare cause of megacolon

The toxic effects of chemotherapy have been noted to cause a range of acute necrotizing colonic inflammatory disorders but until recently these have not been associated with docetaxel chemotherapy. Here we report a case of pancolitis presenting as megacolon following the administration of docetaxel for recurrent breast cancer.

Gastrointestinal complications in the neutropenic patient: characterization and differentiation with abdominal CT

PURPOSE

To characterize the computed tomographic (CT) findings of gastrointestinal complications in neutropenic patients and to identify CT features that can help differentiate these complications.

MATERIALS AND METHODS

Abdominal CT scans obtained during a 6-year period were reviewed retrospectively to identify 76 neutropenic patients with radiologic bowel abnormalities. Scans were analyzed for wall thickening, pneumatosis, wall nodularity, mucosal enhancement, bowel dilatation, ascites, and mesenteric stranding. The location and extent of abnormalities were noted. Independent chart and pathology report reviews were used to determine the patients' final diagnoses: neutropenic enterocolitis (n = 53), Clostridium difficile colitis (n = 14), graft-versus-host disease (n = 7), cytomegaloviral colitis (n = 1), and ischemic bowel (n = 1). Results were assessed with the Student t test for quantitative wall thickness and the chi2 test for the number of patients with each diagnosis who demonstrated each CT finding.

RESULTS

Mean bowel wall thickening was greatest in C difficile colitis (12 mm) and least in graft-versus-host disease (5 mm). Pneumatosis was limited to neutropenic enterocolitis (21% [11 of 53 patients]) and bowel ischemia. Wall nodularity was significantly more common (P <.01) in C difficile colitis (36% [five of 14 patients]). In graft-versus-host disease, the rates of mucosal enhancement and bowel dilatation were highest (P <.05) (71% [five of seven patients] and 86% [six of seven patients], respectively). In C difficile colitis, the rates of ascites and mesenteric stranding were highest (57% [eight of 14 patients] and 71% [10 of 14 patients], respectively). Although findings in neutropenic enterocolitis and graft-versus-host disease could involve any bowel segment, C difficile colitis was always limited to the colon.

CONCLUSION

Several CT findings can help differentiate specific gastrointestinal complications in neutropenic patients.

Neutropenic enterocolitis (typhlitis) after pediatric bone marrow transplant

BACKGROUND/PURPOSE

Neutropenic enterocolitis (typhlitis) is a common consideration after bone marrow transplantation. This study reviews the authors' experience with abdominal pain and typhlitis in an active pediatric bone marrow transplant program.

METHODS

The Pediatric Bone Marrow Transplant Program Database was reviewed for patients presenting with abdominal pain or typhlitis.

RESULTS

From 1993 to 2000 a total of 142 transplants have been performed. Of these, 97 patients had abdominal pain, and 5 had radiologically proven typhlitis. Nonspecific abdominal pain developed on the 12 +/- 11th day posttransplant, whereas patients in whom typhlitis developed were diagnosed on day 15.5 +/- 7. All patients were treated with prophylactic antibiotics consisting of acyclovir, fluconazole, and septra. With the onset of abdominal pain, 73 of 97 patients were placed on therapeutic antibiotics; patients identified with typhlitis had amphotericin plus GCSF added. No clinical features differentiated abdominal pain patients from typhlitis. Oral feeding and time of discharge was similar in both groups. Surgical intervention was not required, and no patients died with typhlitis.

CONCLUSIONS

Abdominal pain is a common symptom after bone marrow transplant; however, typhlitis is relatively rare, and surgical intervention was not required in this series. Broad-spectrum (including fungal) antibiotic therapy appears to be an effective treatment for typhlitis in this patient population.

Gastrointestinal pneumatosis after docetaxel chemotherapy

Breast cancer is one of the most frequent neoplasms in women. New drugs, including taxanes, have improved survival in patients with metastatic disease. Quality of life and efficacy are important goals during treatment of these women. Herein, we report a 51 year-old woman with metastatic breast cancer who developed gastrointestinal pneumatosis (GIP) after the first cycle of treatment, which consisted of docetaxel and pamidronate. The symptoms disappeared after 7 days with supportive management, nasogastric intubation, parenteral fluids, and wide-spectrum antibiotics. Thereafter, weekly fractionated chemotherapy with an initial 50% dose reduction was administered. Because of adequate tolerance, the dose was increased by 25% after the second cycle, and full-dose docetaxel was administered after the third cycle. After 6 months of follow-up, the patient remained under treatment, with an Eastern Cooperative Oncology Group performance status of 1. Gastrointestinal pneumatosis has been reported in association with chemotherapy. In most patients, it is reported to be associated with neutropenia, which was not present in this patient.

Immune-derived opioids and peripheral antinociception

1. Recent findings have suggested a significant involvement of the immune system in the control of pain. Immune cells contain opioid peptides that are released within inflamed tissue and act at opioid receptors on peripheral sensory nerve endings. It is also apparent that different types of lymphocytes contain beta-endorphin, memory T cells containing more beta-endorphin than naïve cells. 2. These findings highlight an integral link between immune cell migration and inflammatory pain. The present review highlights immune system involvement in the site-directed control of inflammatory pain. 3. Full-length mRNA transcripts for opioid precursor proteins are expressed in immune cells. Increased expression of pro-opiomelanocortin mRNA and beta-endorphin has been demonstrated in stimulated lymphocytes and lymphocytes from animals with inflammation. 4. Cytokines and corticotropin-releasing factor (CRF) release opioids from immune cells. Potent peripheral analgesia due to direct injection of CRF can be blocked by antagonists to CRF, antibodies to opioid peptides, antisense to CRF and opioid receptor-specific antagonists. The release of opioid peptides from lymphocytes is calcium dependent and opioid receptor specific. Furthermore, endogenous sources of opioid peptides produce potent analgesia when implanted into the spinal cord. 5. Activated immune cells migrate directly to inflamed tissue using cell adhesion molecules to adhere to the epithelial surface of the vasculature in inflamed tissue. Lymphocytes that have been activated can express opioid peptides. Memory type T cells that contain opioid peptides are present within inflamed tissue; naive cells are not present in inflamed tissue and do not contain opioid peptides. Inhibiting the migration of memory type T cells into inflamed tissue by blocking selectins results in reduced numbers of beta-endorphin-containing cells, a reduced quantity of beta-endorphin in inflamed paws and reduced stress- and CRF-induced peripheral analgesia. 6. Immunosuppression is associated with increased pain in patients. Moreover, immunosuppression results in decreased lymphocyte numbers as well as decreased analgesia in animal models.

Successful conservative treatment of neutropenic enterocolitis complicating taxane-based chemotherapy: a report of five cases

Five cases of acute neutropenic enterocolitis complicating taxane-based chemotherapy are described. During a 34-month period, our department administered 4,600 courses of taxane-based (paclitaxel and docetaxel) chemotherapy to 800 cancer patients. Seven to 10 days postchemotherapy in five patients (0.1% of the given courses), neutropenic fever, abdominal pain, rebound tenderness, and grade II-IV diarrhea (bloody in two cases) developed. Two patients had oral candidiasis, and in two others septic shock developed. Computed tomography scans of the abdomen revealed in all patients thickening of the colon wall and pericolic edema, and a pericolic abscess was revealed in three of them. Both clinical and radiologic findings supported the diagnosis of acute neutropenic enterocolitis. All patients were successfully treated with broad-spectrum antibiotics and recombinant human granulocyte colony-stimulating factor. In conclusion, acute neutropenic enterocolitis is a severe complication of taxane-based chemotherapy. Early diagnosis and appropriate conservative treatment leads to complete recovery. Although rare, this infection is less often associated with other chemotherapeutic regimens.

The approach to common abdominal diagnosis in infants and children

This article focuses on salient points in the evaluation of abdominal pain in infants and children. Specifically, the authors address appendicitis and abdominal pain associated with either vomiting, constipation, or gastrointestinal bleeding. A discussion of common abdominal masses, urologic, and gynecologic problems, and considerations in the evaluation of immunologically suppressed or neurologically impaired children, and children with recurrent abdominal pain is also presented. The authors establish logical, focused approaches to the initial evaluation and management of abdominal pain and suggest criteria for timely surgical referral.

Acute lymphoblastic leukemia presenting with typhlitis

We report an unusual case of acute lymphoblastic leukemia (ALL) that presented as right lower quadrant pain in a 17-year-old boy. Ultrasonographic findings were consistent with typhlitis. The clinical and imaging symptoms resolved upon treatment with antibiotics and conservative care, only to recur after initiation of chemotherapy. Familiarity with the clinical presentation and imaging findings of typhlitis is important for its correct diagnosis and management.

Typhlitis resulting from treatment with taxol and doxorubicin in patients with metastatic breast cancer

BACKGROUND

Typhlitis is being recognized with increasing frequency as a serious complication of aggressive chemotherapy for hematologic and solid malignancies.

METHODS

In this report the authors describe two cases of typhlitis in patients with metastatic breast cancer treated with taxol and doxorubicin.

RESULTS

Both cases occurred during the first cycle of treatment with taxol (180 mg/m2) and doxorubicin (75 mg/m2), being given simultaneously as 72-hour continuous intravenous infusions.

CONCLUSION

Two cases of typhlitis have occurred after combined treatment with taxol and doxorubicin, while typhlitis has not been described after treatment with either drug alone.

Appendicitis in acquired immunodeficiency syndrome

Reports in the surgical literature are few regarding common intra-abdominal disease processes, such as gallstone disease or appendicitis, in patients with AIDS and instead have focused on AIDS-related intra-abdominal diseases that infrequently require surgical intervention unless complicated by bleeding, obstruction, or perforation. A literature review for appendicitis in AIDS patients revealed only 30 well-documented cases drawn from 13 studies, with a 40% perforation rate and frequent delays and errors in diagnosis. A 7-year experience with 28 patients with appendicitis and AIDS from 4 urban San Francisco hospitals is reviewed. There were no perioperative deaths and an 18% postoperative complication rate. Five patients (18%) were found to have normal appendices with other intra-abdominal pathology, and an AIDS-related etiology for appendicitis was discovered in 7 of 23 patients with appendicitis (30%). With the exception of diffuse versus localized abdominal pain, no preoperative symptom or sign was useful in differentiating AIDS-related and non-AIDS-related disease. Aggressive use of ultrasound and abdominal computed tomographic scanning, along with early surgical intervention, is recommended.

Sonographic observations in a patient with typhlitis

The sonographic findings in a patient with typhlitis are presented. Sonography showed a solid mass with a "target" sign in the right lower quadrant, continuous with the ascending colon. In addition to suggesting the diagnosis, sonography was helpful in the follow-up examination of the patient because it was able to assess the gradual decrease in the thickness of the bowel wall and ultimate resolution of the inflammatory process.