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TyphlitisTyphlitis

DefinitionDefinition EpidemiologyEpidemiology PathophysiologyPathophysiology Clinical presentationClinical presentation ComplicationsComplications D.D.D.D. InvestigationsInvestigations ManagementManagement PrognosisPrognosis

What does it mean?What does it mean?

Typhlitis means inflammation of the cecum. Typhlitis means inflammation of the cecum.

It is an acute life-threatening condition It is an acute life-threatening condition characterized by transmural inflammation characterized by transmural inflammation involving ileum, cecum, or appendix in involving ileum, cecum, or appendix in patients who are severely myelosuppressed patients who are severely myelosuppressed and immunosuppressed. and immunosuppressed.

What does It Mean?What does It Mean?

Associated with:Associated with:

Aplastic anemia.Aplastic anemia.

Lymphoma.Lymphoma.

AIDS.AIDS.

Immunosuppression following renal Immunosuppression following renal

transplantation or during treatment of transplantation or during treatment of

malignancy. malignancy.

EpidemiologyEpidemiology

found in 10% of leukemic children who died while found in 10% of leukemic children who died while undergoing chemotherapy.undergoing chemotherapy.

mortality rate averages 40-50% (cecal perforation, mortality rate averages 40-50% (cecal perforation, bowel necrosis, or sepsis).bowel necrosis, or sepsis).

Prevalence is equal in males and females.Prevalence is equal in males and females.

Typhlitis occurs in both children and adults.Typhlitis occurs in both children and adults.

PathophysiologyPathophysiology

The etiology of typhlitis is unknown but pathogenesis The etiology of typhlitis is unknown but pathogenesis is multifactorail.is multifactorail.

Profound neutropenia, with total neutrophil counts of Profound neutropenia, with total neutrophil counts of less than 1000 appears to be a universal predisposing less than 1000 appears to be a universal predisposing factor. factor.

Mucosal injury from cytotoxic drugs plays an Mucosal injury from cytotoxic drugs plays an important role in the typhlitis observed during important role in the typhlitis observed during chemotherapy. chemotherapy.

PathophysiologyPathophysiology Cecal distension in typhlitis may impair the blood supply, Cecal distension in typhlitis may impair the blood supply,

leading to mucosal ischemia and ulceration.leading to mucosal ischemia and ulceration.

Infection may be involved, especially cytomegalovirus. Infection may be involved, especially cytomegalovirus. Bacterial invasion leads to transmural penetration and Bacterial invasion leads to transmural penetration and ultimately perforation. ultimately perforation.

Mucosal and submucosal necrosis can result in intramural Mucosal and submucosal necrosis can result in intramural hemorrhage. hemorrhage.

Neoplastic infiltration may be involved in some patients. Neoplastic infiltration may be involved in some patients.

Clinical ManifestationsClinical Manifestations

Watery or bloody diarrhea Watery or bloody diarrhea Fever Fever Nausea Nausea Vomiting Vomiting Abdominal pain (may be localized to right Abdominal pain (may be localized to right

lower quadrant) lower quadrant) Possible shock secondary to septicemia or Possible shock secondary to septicemia or

colonic perforationcolonic perforation

Clinical FindingsClinical Findings

Abdominal distension Abdominal distension Palpation tenderness (usually most marked in Palpation tenderness (usually most marked in

RLQ) RLQ) Occasionally, a palpable mass Occasionally, a palpable mass Diffuse direct and rebound tenderness Diffuse direct and rebound tenderness

(suggesting colonic perforation, peritonitis)(suggesting colonic perforation, peritonitis) Hyper-resonant abdomenHyper-resonant abdomen Absence of bowel sounds Absence of bowel sounds

D.D.D.D.

Acute Appendicitis.Acute Appendicitis.

I.B.D.I.B.D.

Enterocolitis.Enterocolitis.

Toxic Megacolon.Toxic Megacolon.

Small bowel obstruction.Small bowel obstruction.

ComplicationsComplications

Bowel perforation and peritonitisBowel perforation and peritonitis Gastrointestinal bleedingGastrointestinal bleeding Gastrointestinal obstructionGastrointestinal obstruction Intra-abdominal abscessIntra-abdominal abscess SepsisSepsis DeathDeath

InvestigationsInvestigations

Complete blood count is used to confirm Complete blood count is used to confirm neutropenia.neutropenia.

Stool studies are obtained for the following:Stool studies are obtained for the following: Clostridium difficileClostridium difficile toxin to rule out toxin to rule out

pseudomembranous colitis.pseudomembranous colitis. Culture for enteric pathogens to rule out infectious Culture for enteric pathogens to rule out infectious

causes of enterocolitis.causes of enterocolitis.

InvestigationsInvestigations

AXR:AXR: Plain radiographs are nonspecific but may Plain radiographs are nonspecific but may

demonstrate a fluid-filled masslike density in demonstrate a fluid-filled masslike density in the RLQ, distension of adjacent small bowel the RLQ, distension of adjacent small bowel loops, and thumbprinting. Free intraperitoneal loops, and thumbprinting. Free intraperitoneal air and pneumatosis coli rarely are observed. air and pneumatosis coli rarely are observed. Barium enema and colonoscopy are Barium enema and colonoscopy are contraindicated in possible typhlitis because of contraindicated in possible typhlitis because of perforation risk. perforation risk.

InvestigationsInvestigations

CT Abdomen:CT Abdomen: CT demonstrates circumferential and occasionally CT demonstrates circumferential and occasionally

eccentric low-attenuation colonic wall thickening and eccentric low-attenuation colonic wall thickening and cecal distension. High attenuation within the cecal distension. High attenuation within the thickened colonic wall may represent hemorrhage. thickened colonic wall may represent hemorrhage. Inflammatory pericolonic stranding of mesenteric fat Inflammatory pericolonic stranding of mesenteric fat is common. is common.

CT readily identifies complications, including CT readily identifies complications, including pneumatosis coli, pneumoperitoneum, pericolonic pneumatosis coli, pneumoperitoneum, pericolonic fluid collections, and abscess. These complications fluid collections, and abscess. These complications may require urgent surgical management. may require urgent surgical management.

ManagementManagement

ConservativeConservative

SurgicalSurgical

ManagementManagement

Conservative management includes the following:Conservative management includes the following:

Bowel rest and nasogastric suction Bowel rest and nasogastric suction

Close monitoring of patients using serial abdominal Close monitoring of patients using serial abdominal examinations in an intensive care settingexaminations in an intensive care setting

Intravenous fluids, blood, and platelet transfusions as Intravenous fluids, blood, and platelet transfusions as necessarynecessary

ManagementManagement

Parenteral broad-spectrum antibiotics: Antibiotics Parenteral broad-spectrum antibiotics: Antibiotics should include agents covering enteric gram-should include agents covering enteric gram-negative and anaerobic organisms, including negative and anaerobic organisms, including ClostridiumClostridium species. Metronidazole also may be species. Metronidazole also may be considered if pseudomembranous colitis cannot considered if pseudomembranous colitis cannot immediately be excluded.immediately be excluded.

Cultures: Obtain blood cultures for fungus and Cultures: Obtain blood cultures for fungus and consider antifungal agents if patients do not consider antifungal agents if patients do not respond to antibiotics.respond to antibiotics.

ManagementManagement

Avoidance of certain medications: Anticholinergic Avoidance of certain medications: Anticholinergic agents, antidiarrheal drugs, and narcotics may agents, antidiarrheal drugs, and narcotics may worsen the condition or further confuse the clinical worsen the condition or further confuse the clinical picture.picture.

Surgical ManagementSurgical Management

indications:indications: Free intra-abdominal perforationFree intra-abdominal perforation Clinical deterioration during conservative medical Clinical deterioration during conservative medical

therapytherapy Differentiation from other acute abdominal Differentiation from other acute abdominal

conditions for which surgery is indicatedconditions for which surgery is indicated Unrelenting intra-abdominal sepsis or abscess Unrelenting intra-abdominal sepsis or abscess

formationformation Continued hemorrhage with a platelet count and Continued hemorrhage with a platelet count and

coagulation parameters within the reference rangecoagulation parameters within the reference range

Surgical ManagementSurgical Management

Choice of surgical procedures includes the Choice of surgical procedures includes the following: following:

1) Cecostomy and drainage 1) Cecostomy and drainage 2) A 2-stage right hemicolectomy or 2) A 2-stage right hemicolectomy or total abdominal colectomy, with or total abdominal colectomy, with or without a primary anastomosis without a primary anastomosis 3) Defunctioning of the colon with a 3) Defunctioning of the colon with a loop ileostomyloop ileostomy

PrognosisPrognosis

The prognosis generally is poor, with mortality The prognosis generally is poor, with mortality rates varying from 5-100% and averaging rates varying from 5-100% and averaging about 40-50%.about 40-50%.

The prognosis depends highly on the rapidity The prognosis depends highly on the rapidity of restoration of the white blood cell count.of restoration of the white blood cell count.

The potential for recovery may be improved The potential for recovery may be improved by aggressive and meticulous medical and by aggressive and meticulous medical and supportive therapy.supportive therapy.

SummarySummary

Consider the possibility of neutropenic enterocolitis Consider the possibility of neutropenic enterocolitis in all patients who are immunosuppressed and have in all patients who are immunosuppressed and have right lower quadrant pain.right lower quadrant pain.

Early recognition of this condition is paramount to Early recognition of this condition is paramount to reducing mortality rates and achieving a potentially reducing mortality rates and achieving a potentially good outcome.good outcome.

Monitor the patient in an intensive care setting with Monitor the patient in an intensive care setting with frequent serial abdominal examinations.frequent serial abdominal examinations.

Joint management by the medical and surgical teams Joint management by the medical and surgical teams is essential for optimal management.is essential for optimal management.

Thank YouThank You

Hana’a TashkandiHana’a Tashkandi