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Indian Journal of Cancer, Vol. 44, No. 3, July-September, 2007, pp. 122-123 Case Report Neutropenic enterocolitis Singhal M, Lal A, Vyas S, Gulati A Department of Radiodiagnosis and Imaging, Postgraduate Institute of Medical Education and Research, Chandigarh - 160 012 Code Number: cn07022 Abstract We report a case of neutropenic enterocolitis diagnosed on computerized tomography abdomen in a 56-year-old man having high-grade non-Hodgkin's lymphoma. After appropriate management, the patient recovered completely.Keywords: Colitis, neutropenia, non-Hodgkin′s lymphoma Introduction Neutropenic colitis is a condition characterized by inflammation, which usually involves caecum, colon and a terminal part of ileum in patients of neutropenia. [1] Its recognition in appropriate clinical setting is of utmost importance as this condition can cause unmanageable complications. [1],[2],[3] The diagnosis is most often radiological, and the disease responds to conservative management.Case Report A 56-year-old man having high-grade non-Hodgkin′s lymphoma (NHL) localized to the cervical and mediastinal lymph nodes presented with fever over 39°C, pain on the right lower abdomen and watery diarrhea, 12 days after the initiation of chemotherapy for NHL (CHOP - cyclophosphamide, vincristine, doxorubicin and prednisolone) in recommended doses. CECT abdomen was performed, which demonstrated diffuse circumferential thickening of caecal and ascending colonic walls with inflammatory stranding of the pericaecal and colonic fat [Figure - 1] a and b. In addition, distal ileal loops showed mural thickening with minimal inflammatory stranding [Figure - 2]. There was no free fluid, enlarged lymph nodes or pneumatosis intestinalis. Laboratory evaluation showed neutropenia (460 neutrophils/mm 3 ). Based on the clinical and radiological findings, the diagnosis of neutropenic colitis was made. The patient was managed conservatively with bowel rest with nasogastric intubation, parenteral nutrition and broad-spectrum antibiotics (pipracillin, tazobactum and metronidozole). He responded well to treatment, and a follow-up imaging after a week showed regression of imaging findings. Neutropenic colitis, also known as typhlitis or ileo-caecal syndrome, is a clinico-pathological condition characterized by a septic or inflammatory abdominal process that may involve caecum, colon and a terminal part of ileum in patients of neutropenia. [1] This disease is most often associated with hematological malignancies like leukemia and lymphoma; however, with the advent of new anti-cancer days and intensified chemotherapy, neutropenic colitis has been reported in patients receiving chemotherapy for solid cancers. [1],[2] Neutropenic colitis, which is generally characterized by edema and inflammation of the caecum, ascending colon and terminal ileum, may at times be so severe that transmural necrosis, perforation and death can result due to septicemia. [1],[2],[3] Etiopathogensis of this condition is not precisely known, but temporal association of the administration of anti-cancer drugs with subsequent development of neutropenic colitis suggests that cytotoxic drug-induced mucosal injury plays a significant role is the genesis of this disease. Several other factors contribute to mucosal injury too, which include a combination of local bacterial and fungal infections, necrosis of mural leukemic infiltrates, mucosal hemorrhage, stasis of bowel contents with epithelial erosion and mucosal ischemia from sepsis-induced hypotension. [1],[2] Caecum is the most common site of involvement, probably due to relative stasis of bowel contents and distensibility of the caecum with compromise in its blood supply. [2] Clinically, the patient presents with fever, watery diarrhea, abdomen distention and abdominal pain, which may be localized to the right lower quadrant. [1],[2] The diagnosis of this condition is radiological due to the absence of the risk of bowel perforation when compared to colonoscopy or contrast enema evaluation. Ultrasound reveals an enlarged caecum with characteristic echogenic thickening of the mucosa, with or without fluid collection. [1],[2],[3] In complicated situations like caecal perforation, bowel necrosis and abscess formation, sonography is inadequate, which are the main reasons for mortality. In such conditions, CT not only effectively identifies the disease but also its complications, which is very crucial for further management; hence CT remains the imaging modality of choice. CT reveals a thickening of the caecal and right colonic walls with caecal distension and inflammatory stranding of pericolonic fat. In a complicated case, it demonstrates pneumatosis intestinalis, pneumo-peritoneum, ascitis and abscess, which indicate the need for urgent surgical intervention. [2],[3],[4] The management of neutropenic colitis ranges from supportive care to emergency surgery. Supportive care comprises of bowel rest with nasogastric decompression, parenteral nutrition and fluid replacement, and broad-spectrum antibiotics. [4],[5] Despite aggressive management, mortality rates are high upto 21-48%. [1] Neutropenic colitis is a clinico-pathological condition most often seen in patients of lymphomas and leukemias. In clinically suspected cases, CT scan of abdomen should be done, which is diagnostic and can guide further management. References
Copyright 2007 - Indian Journal of Cancer The following images related to this document are available:Photo images[cn07022f1.jpg] [cn07022f2.jpg] |
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