eMedicine Specialties > Gastroenterology > Colon

Neutropenic Enterocolitis: Differential Diagnoses & Workup

Author: Keith Sultan, MD, Faculty Practice, Division of Gastroenterology, Hepatology and Nutrition, North Shore University Hospital, Manhasset, New York
Coauthor(s): Rajeev Vasudeva, MD, FACG, Clinical Professor of Medicine, Consultants in Gastroenterology, University of South Carolina School of Medicine
Contributor Information and Disclosures

Updated: Jul 9, 2009

Differential Diagnoses

Appendicitis
Ogilvie Syndrome
Gastroenteritis, Bacterial
Pseudomembranous Colitis
Gastroenteritis, Viral
Inflammatory Bowel Disease
Megacolon, Acute

Other Problems to Be Considered

Intussusception
Ischemic colitis
Leukemic or lymphomatous infiltration of the bowel wall
Small bowel obstruction

Workup

Laboratory Studies

  • A complete blood cell (CBC) count is used to confirm neutropenia.
  • A serum bicarbonate level and pH value should be obtained to rule out acidosis.
  • Stool studies are obtained for the following:
    • Clostridium difficile toxin to rule out pseudomembranous colitis
    • Culture for enteric pathogens to rule out infectious causes of enterocolitis
  • Blood cultures are obtained for aerobic/anaerobic bacteria and fungus to rule out bacterial and fungal sepsis.

Imaging Studies

  • Plain abdominal radiographs rarely help in the diagnosis of neutropenic enterocolitis (typhlitis). Radiographic findings usually are nonspecific and may even be normal. Nonspecific findings may include the following:
    • Right-sided colonic and small bowel dilatation
    • Thumbprinting (see Image 5 or below) of the right colon
      Plain abdominal radiograph in a 44-year-old man k...

      Plain abdominal radiograph in a 44-year-old man known to have long history of ulcerative colitis. The patient presented with an acute exacerbation of symptoms. Image shows thumbprinting in the region of the splenic flexure of the colon.

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      Plain abdominal radiograph in a 44-year-old man k...

      Plain abdominal radiograph in a 44-year-old man known to have long history of ulcerative colitis. The patient presented with an acute exacerbation of symptoms. Image shows thumbprinting in the region of the splenic flexure of the colon.

    • Paucity of air in the right colon due to a fluid-filled colon
    • Intramural air or pneumatosis
    • Soft-tissue mass displacing the small bowel
  • Barium enema is usually contraindicated, especially if a potential for perforation exists. Water-soluble contrast may demonstrate rigidity and thickening of the cecum.
  • Abdominal ultrasonography
    • Abdominal ultrasonography is one of the most important diagnostic studies for neutropenic enterocolitis (typhlitis), and it is preferable to contrast enemas. This may be useful as a follow-up tool to assess the gradual decrease in bowel wall thickening.
    • Findings include thickening of the bowel wall that produces a target or halo sign. However, this is a nonspecific finding and may be observed in other conditions listed under the differential diagnosis (see Differentials).
    • Bowel wall thickness has also been suggested as a significant prognostic factor regarding patient outcome in individuals with neutropenic enterocolitis (typhlitis). A retrospective study using ultrasonography showed that a bowel wall thickness of greater than 5 mm was associated with a higher mortality (29%) than in those without bowel wall thickening (0%).18 If one takes a bowel wall thickness cutoff of greater than 10 mm, the mortality was 60% compared with 4.2% in those without bowel wall thickening.
    • Bowel wall thickening has also been associated with the duration of illness and neutropenia in neutropenic enterocolitis (typhlitis).19
    • Ultrasonography also allows for follow-up imaging without repeated exposure to ionizing radiation, an especially important consideration in children and younger adults.
  • Computed tomography (CT) scanning of the abdomen is the diagnostic procedure of choice in neutropenic enterocolitis (typhlitis), because this imaging modality has a lower false-negative rate (15%) compared with ultrasonography (23%) or plain abdominal radiographs (48%) (see Images 6-7 or below). CT scanning is the test of choice to diagnose alternative causes of abdominal pain such as megacolon, appendicitis, and small bowel obstruction.16,20,21  
    Typhlitis. Marked asymmetric cecal wall thickenin...

    Typhlitis. Marked asymmetric cecal wall thickening (arrow) in a 64-year-old patient whose status is postchemotherapeutic for lymphoma.

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    Typhlitis. Marked asymmetric cecal wall thickenin...

    Typhlitis. Marked asymmetric cecal wall thickening (arrow) in a 64-year-old patient whose status is postchemotherapeutic for lymphoma.


    Typhlitis. Marked circumferential cecal and ascen...

    Typhlitis. Marked circumferential cecal and ascending colon wall thickening (large arrows) with mild pericolonic inflammatory stranding (small arrows).

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    Typhlitis. Marked circumferential cecal and ascen...

    Typhlitis. Marked circumferential cecal and ascending colon wall thickening (large arrows) with mild pericolonic inflammatory stranding (small arrows).

    Findings include the following:
    • Symmetrical thickening of the cecum
    • Fluid-filled cecum
    • Pericecal inflammation
    • Free air if an underlying perforation exists
    • Portal venous gas

Procedures

  • Endoscopic procedures include colonoscopy or flexible sigmoidoscopy.
    • These procedures are relatively contraindicated in patients with neutropenic enterocolitis (typhlitis) due to an increased risk of complications, especially in the setting of underlying neutropenia and thrombocytopenia.
    • Usually, these procedures are unnecessary, except in rare circumstances in which a gentle sigmoidoscopy may aid in the diagnosis of pseudomembranous colitis (see Image 2 or below).
      Colonic pseudomembranes of pseudomembranous colit...

      Colonic pseudomembranes of pseudomembranous colitis. Photographs courtesy of Eric M. Osgard, MD.

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      Colonic pseudomembranes of pseudomembranous colit...

      Colonic pseudomembranes of pseudomembranous colitis. Photographs courtesy of Eric M. Osgard, MD.

Histologic Findings

Gross and microscopic findings of neutropenic enterocolitis (typhlitis) include diffuse bowel wall thickening with mucosal and intramural edema and necrosis, mucosal ulcerations, and intramural or intraluminal hemorrhage. The bowel wall specimens obtained during colectomy or at autopsy demonstrate an abundance of bacteria, a striking lack of lymphoid inflammatory cells, and a virtual absence of neutrophils.

More on Neutropenic Enterocolitis

Overview: Neutropenic Enterocolitis
Differential Diagnoses & Workup: Neutropenic Enterocolitis
Treatment & Medication: Neutropenic Enterocolitis
Follow-up: Neutropenic Enterocolitis
Multimedia: Neutropenic Enterocolitis
References
Further Reading
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References

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Further Reading

Related eMedicine Topics

National Guideline Clearinghouse

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Keywords

neutropenic enterocolitis, typhlitis, necrotizing enterocolitis, ileocecal syndrome, pseudomembranous colitis, typhlitis, acute ileocecal enterocolitis, transmural inflammation of the small bowel and large bowel in myelosuppression and immunosuppression, profound neutropenia, cecum, ileum, ascending colon, cecitis, right lower quadrant pain

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Contributor Information and Disclosures

Author

Keith Sultan, MD, Faculty Practice, Division of Gastroenterology, Hepatology and Nutrition, North Shore University Hospital, Manhasset, New York
Keith Sultan, MD is a member of the following medical societies: American College of Gastroenterology and American Gastroenterological Association
Disclosure: Nothing to disclose.

Coauthor(s)

Rajeev Vasudeva, MD, FACG, Clinical Professor of Medicine, Consultants in Gastroenterology, University of South Carolina School of Medicine
Rajeev Vasudeva, MD, FACG is a member of the following medical societies: American College of Gastroenterology, American Gastroenterological Association, American Society for Gastrointestinal Endoscopy, Columbia Medical Society, South Carolina Gastroenterology Association, and South Carolina Medical Association
Disclosure: Pricara Honoraria Speaking and teaching; UCB Consulting fee Consulting

Medical Editor

Robert J Fingerote, MD, MSc, BSc, FRCPC, Consultant, Clinical Evaluation Division, Biologic and Gene Therapies, Directorate Health Canada; Consulting Staff, Department of Medicine, Division of Gastroenterology, York Central Hospital, Richmond Hill, Ontario
Robert J Fingerote, MD, MSc, BSc, FRCPC is a member of the following medical societies: American Association for the Study of Liver Diseases, American Gastroenterological Association, Canadian Medical Association, Ontario Medical Association, and Royal College of Physicians and Surgeons of Canada
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Douglas M Heuman, MD, FACP, FACG, AGAF, Chief of Hepatology, Hunter Holmes McGuire Department of Veterans Affairs Medical Center; Professor, Department of Internal Medicine, Division of Gastroenterology, Virginia Commonwealth University School of Medicine
Douglas M Heuman, MD, FACP, FACG, AGAF is a member of the following medical societies: American Association for the Study of Liver Diseases, American College of Physicians, and American Gastroenterological Association
Disclosure: Nothing to disclose.

CME Editor

Alex J Mechaber, MD, FACP, Associate Dean for Undergraduate Medical Education, Associate Professor of Medicine, University of Miami Miller School of Medicine
Alex J Mechaber, MD, FACP is a member of the following medical societies: Alpha Omega Alpha, American College of Physicians-American Society of Internal Medicine, and Society of General Internal Medicine
Disclosure: Nothing to disclose.

Chief Editor

Julian Katz, MD, Clinical Professor of Medicine, Drexel University College of Medicine; Consulting Staff, Department of Medicine, Section of Gastroenterology and Hepatology, Hospital of the Medical College of Pennsylvania
Julian Katz, MD is a member of the following medical societies: American College of Gastroenterology, American College of Physicians, American Gastroenterological Association, American Geriatrics Society, American Medical Association, American Society for Gastrointestinal Endoscopy, American Society of Law Medicine and Ethics, American Trauma Society, Association of American Medical Colleges, and Physicians for Social Responsibility
Disclosure: Nothing to disclose.

 
 
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