Close
New

Medscape is available in 5 Language Editions – Choose your Edition here.

 

Neutropenic Enterocolitis Workup

  • Author: Keith Sultan, MD, FACG; Chief Editor: BS Anand, MD  more...
 
Updated: Nov 06, 2015
 

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.

Next

Imaging Studies

Radiography

Plain abdominal radiographs rarely help in the diagnosis of neutropenic enterocolitis. 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 below) of the right colon
    Plain abdominal radiograph in a 44-year-old man kn 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, and it is preferable to contrast enemas. Ultrasonography may be also 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.[23, 24] 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%).[25] 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.[26]

Ultrasonography also allows for follow-up imaging without repeated exposure to ionizing radiation, an especially important consideration in children and younger adults.

Computed tomography scanning

Computed tomography (CT) scanning of the abdomen is the diagnostic procedure of choice in neutropenic enterocolitis, because this imaging modality has a lower false-negative rate (15%) compared with ultrasonography (23%) or plain abdominal radiographs (48%) (see images below). CT scanning is the test of choice to diagnose alternative causes of abdominal pain such as megacolon, appendicitis, and small bowel obstruction.[11, 27, 28]

Typhlitis. Marked asymmetric cecal wall thickening Typhlitis. Marked asymmetric cecal wall thickening (arrow) in a 64-year-old patient whose status is postchemotherapeutic for lymphoma.
Typhlitis. Marked circumferential cecal and ascend Typhlitis. Marked circumferential cecal and ascending colon wall thickening (large arrows) with mild pericolonic inflammatory stranding (small arrows).

CT scan findings include the following:

  • Symmetrical thickening of the cecum
  • Fluid-filled cecum
  • Pericecal inflammation
  • Free air if an underlying perforation exists
  • Portal venous gas
Previous
Next

Procedures

Endoscopic procedures include colonoscopy or flexible sigmoidoscopy.

These procedures are relatively contraindicated in patients with neutropenic enterocolitis 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 images below).

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

Histologic Findings

Gross and microscopic findings of neutropenic enterocolitis 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.

Previous
 
 
Contributor Information and Disclosures
Author

Keith Sultan, MD, FACG Assistant Professor of Medicine, Division of Gastroenterology, Hofstra North Shore-LIJ School of Medicine

Keith Sultan, MD, FACG is a member of the following medical societies: American College of Gastroenterology, American Gastroenterological Association

Disclosure: Nothing to disclose.

Coauthor(s)

Rajeev Vasudeva, MD Clinical Professor of Medicine, Consultants in Gastroenterology, University of South Carolina School of Medicine

Rajeev Vasudeva, MD is a member of the following medical societies: American College of Gastroenterology, Columbia Medical Society, South Carolina Gastroenterology Association, American Gastroenterological Association, American Society for Gastrointestinal Endoscopy, South Carolina Medical Association

Disclosure: Received honoraria from Pricara for speaking and teaching; Received consulting fee from UCB for consulting.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Chief Editor

BS Anand, MD Professor, Department of Internal Medicine, Division of Gastroenterology, Baylor College of Medicine

BS Anand, MD is a member of the following medical societies: American Association for the Study of Liver Diseases, American College of Gastroenterology, American Gastroenterological Association, American Society for Gastrointestinal Endoscopy

Disclosure: Nothing to disclose.

Additional Contributors

Robert J Fingerote, MD, MSc, FRCPC Consultant, Clinical Evaluation Division, Biologic and Gene Therapies, Directorate Health Canada; Consulting Staff, Department of Medicine, Division of Gastroenterology, York Central Hospital, Ontario

Robert J Fingerote, MD, MSc, FRCPC is a member of the following medical societies: American Association for the Study of Liver Diseases, American Gastroenterological Association, Ontario Medical Association, Royal College of Physicians and Surgeons of Canada, Canadian Medical Association

Disclosure: Nothing to disclose.

Acknowledgements

Douglas M Heuman, MD, FACP, FACG, AGAF Chief of GI, Hepatology, and Nutrition at North Shore University Hospital/Long Island Jewish Medical Center; Professor, Department of Medicine, Hofstra North Shore-LIJ 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: Novartis Grant/research funds Other; Bayer Grant/research funds Other; Otsuka Grant/research funds None; Bristol Myers Squibb Grant/research funds Other; Scynexis None None; Salix Grant/research funds Other; MannKind Other

References
  1. Keidan RD, Fanning J, Gatenby RA, Weese JL. Recurrent typhlitis. A disease resulting from aggressive chemotherapy. Dis Colon Rectum. 1989 Mar. 32(3):206-9. [Medline].

  2. Wade DS, Nava HR, Douglass HO Jr. Neutropenic enterocolitis. Clinical diagnosis and treatment. Cancer. 1992 Jan 1. 69(1):17-23. [Medline].

  3. Davila AD, Willenbucher RF. Neutropenic typhlitis. Feldman M, Sleisenger MH, eds. Sleisenger and Fordtran's Gastrointestinal and Liver Disease: Pathophysiology, Diagnosis, Management. 6th ed. Philadelphia, Pa: Saunders; 1998. 1998-2000.

  4. Gorbach SL. Neutropenic enterocolitis. Clin Infect Dis. 1998 Oct. 27(4):700-1. [Medline].

  5. Urbach DR, Rotstein OD. Typhlitis. Can J Surg. 1999 Dec. 42(6):415-9. [Medline].

  6. Gorschluter M, Mey U, Strehl J, et al. Neutropenic enterocolitis in adults: systematic analysis of evidence quality. Eur J Haematol. 2005 Jul. 75(1):1-13. [Medline].

  7. Davila ML. Neutropenic enterocolitis. Curr Opin Gastroenterol. 2006 Jan. 22(1):44-7. [Medline].

  8. Ullery BW, Pieracci FM, Rodney JR, Barie PS. Neutropenic enterocolitis. Surg Infect (Larchmt). 2009 Jun. 10(3):307-14. [Medline].

  9. Wagner ML, Rosenberg HS, Fernbach DJ, Singleton EB. Typhlitis: a complication of leukemia in childhood. Am J Roentgenol Radium Ther Nucl Med. 1970 Jun. 109(2):341-50. [Medline].

  10. Gorschluter M, Mey U, Strehl J, et al. Invasive fungal infections in neutropenic enterocolitis: a systematic analysis of pathogens, incidence, treatment and mortality in adult patients. BMC Infect Dis. 2006 Feb 26. 6:35. [Medline]. [Full Text].

  11. Marie I, Robaday S, Kerleau JM, Jardin F, Levesque H. Typhlitis as a complication of alemtuzumab therapy. Haematologica. 2007 May. 92(5):e62-3. [Medline].

  12. Kasturi KS, Mummadi RR, Sood GK. Neutropenic enterocolitis: An unusual complication of HCV combination therapy with PEG-IFN and ribavirin. Eur J Intern Med. 2008 Jul. 19(5):372-3. [Medline].

  13. Kim JH, Jang JW, You CR, You SY, Jung MK, Jung JH. Fatal Neutropenic Enterocolitis during Pegylated Interferon and Ribavirin Combination Therapy for Chronic Hepatitis C Virus Infection. Gut Liver. 2009 Sep. 3(3):218-21. [Medline].

  14. Katz JA, Wagner ML, Gresik MV, Mahoney DH Jr, Fernbach DJ. Typhlitis. An 18-year experience and postmortem review. Cancer. 1990 Feb 15. 65(4):1041-7. [Medline].

  15. Shamberger RC, Weinstein HJ, Delorey MJ, Levey RH. The medical and surgical management of typhlitis in children with acute nonlymphocytic (myelogenous) leukemia. Cancer. 1986 Feb 1. 57(3):603-9. [Medline].

  16. Fike FB, Mortellaro V, Juang D, St Peter SD, Andrews WS, Snyder CL. Neutropenic colitis in children. J Surg Res. 2011 Sep. 170(1):73-6. [Medline].

  17. Jain Y, Arya LS, Kataria R. Neutropenic enterocolitis in children with acute lymphoblastic leukemia. Pediatr Hematol Oncol. 2000 Jan-Feb. 17(1):99-103. [Medline].

  18. Buyukasik Y, Ozcebe OI, Haznedaroglu IC, et al. Neutropenic enterocolitis in adult leukemias. Int J Hematol. 1997 Jul. 66(1):47-55. [Medline].

  19. Aksoy DY, Tanriover MD, Uzun O, et al. Diarrhea in neutropenic patients: a prospective cohort study with emphasis on neutropenic enterocolitis. Ann Oncol. 2007 Jan. 18(1):183-9. [Medline].

  20. Gil L, Poplawski D, Mol A, Nowicki A, Schneider A, Komarnicki M. Neutropenic enterocolitis after high-dose chemotherapy and autologous stem cell transplantation: incidence, risk factors, and outcome. Transpl Infect Dis. 2013 Feb. 15(1):1-7. [Medline].

  21. El-Matary W, Soleimani M, Spady D, Belletrutti M. Typhlitis in children with malignancy: a single center experience. J Pediatr Hematol Oncol. 2011 Apr. 33(3):e98-100. [Medline].

  22. Mullassery D, Bader A, Battersby AJ, et al. Diagnosis, incidence, and outcomes of suspected typhlitis in oncology patients--experience in a tertiary pediatric surgical center in the United Kingdom. J Pediatr Surg. 2009 Feb. 44(2):381-5. [Medline].

  23. Rizzatti M, Brandalise SR, de Azevedo AC, Pinheiro VR, Aguiar Sdos S. Neutropenic enterocolitis in children and young adults with cancer: prognostic value of clinical and image findings. Pediatr Hematol Oncol. 2010 Sep. 27(6):462-70. [Medline].

  24. Dietrich CF, Hermann S, Klein S, Braden B. Sonographic signs of neutropenic enterocolitis. World J Gastroenterol. 2006 Mar 7. 12(9):1397-402. [Medline].

  25. Cartoni C, Dragoni F, Micozzi A, et al. Neutropenic enterocolitis in patients with acute leukemia: prognostic significance of bowel wall thickening detected by ultrasonography. J Clin Oncol. 2001 Feb 1. 19(3):756-61. [Medline].

  26. McCarville MB, Adelman CS, Li C, et al. Typhlitis in childhood cancer. Cancer. 2005 Jul 15. 104(2):380-7. [Medline]. [Full Text].

  27. Kirkpatrick ID, Greenberg HM. Gastrointestinal complications in the neutropenic patient: characterization and differentiation with abdominal CT. Radiology. 2003 Mar. 226(3):668-74. [Medline]. [Full Text].

  28. Horton KM, Corl FM, Fishman EK. CT evaluation of the colon: inflammatory disease. Radiographics. 2000 Mar-Apr. 20(2):399-418. [Medline]. [Full Text].

  29. [Guideline] Andreyev HJ, Davidson SE, Gillespie C, Allum WH, Swarbrick E. Practice guidance on the management of acute and chronic gastrointestinal problems arising as a result of treatment for cancer. Gut. 2012 Feb. 61(2):179-92. [Medline]. [Full Text].

  30. Cardona Zorrilla AF, Reveiz Herault L, Casasbuenas A, Aponte DM, Ramos PL. Systematic review of case reports concerning adults suffering from neutropenic enterocolitis. Clin Transl Oncol. 2006 Jan. 8(1):31-8. [Medline].

  31. Gafter-Gvili A, Fraser A, Paul M, Leibovici L. Meta-analysis: antibiotic prophylaxis reduces mortality in neutropenic patients. Ann Intern Med. 2005 Jun 21. 142(12 pt 1):979-95. [Medline].

  32. Kuderer NM, Dale DC, Crawford J, Lyman GH. Impact of primary prophylaxis with granulocyte colony-stimulating factor on febrile neutropenia and mortality in adult cancer patients receiving chemotherapy: a systematic review. J Clin Oncol. 2007 Jul 20. 25(21):3158-67. [Medline].

  33. Cardona Zorrilla AF, Reveiz Herault L, Casasbuenas A, Aponte DM, Ramos PL. Systematic review of case reports concerning adults suffering from neutropenic enterocolitis. Clin Transl Oncol. 2006 Jan. 8(1):31-8. [Medline].

  34. Alt B, Glass NR, Sollinger H. Neutropenic enterocolitis in adults. Review of the literature and assessment of surgical intervention. Am J Surg. 1985 Mar. 149(3):405-8. [Medline].

  35. Avigan D, Richardson P, Elias A, et al. Neutropenic enterocolitis as a complication of high dose chemotherapy with stem cell rescue in patients with solid tumors: a case series with a review of the literature. Cancer. 1998 Aug 1. 83(3):409-14. [Medline]. [Full Text].

  36. Badgwell BD, Cormier JN, Wray CJ, et al. Challenges in surgical management of abdominal pain in the neutropenic cancer patient. Ann Surg. 2008 Jul. 248(1):104-9. [Medline].

  37. Crosby WH, Haubrich WS. The death of Walter Reed. JAMA. 1982 Sep 17. 248(11):1342-5. [Medline].

  38. Cunningham SC, Fakhry K, Bass BL, Napolitano LM. Neutropenic enterocolitis in adults: case series and review of the literature. Dig Dis Sci. 2005 Feb. 50(2):215-20. [Medline].

  39. Ettinghausen SE. Collagenous colitis, eosinophilic colitis, and neutropenic colitis. Surg Clin North Am. 1993 Oct. 73(5):993-1016. [Medline].

  40. Gomez L, Martino R, Rolston KV. Neutropenic enterocolitis: spectrum of the disease and comparison of definite and possible cases. Clin Infect Dis. 1998 Oct. 27(4):695-9. [Medline].

  41. Hanada T, Ono I, Hirano C, Kurosaki Y. Successful treatment of neutropenic enterocolitis with recombinant granulocyte colony stimulating factor in a child with acute lymphocytic leukaemia. Eur J Pediatr. 1990 Aug. 149(11):811-2. [Medline].

  42. Hoelzer D. Hematopoietic growth factors--not whether, but when and where. N Engl J Med. 1997 Jun 19. 336(25):1822-4. [Medline].

  43. Kulaylat M, Doerr R, Ambrus J. A case presentation and review of neutropenic enterocolitis. J Med. 1997. 28(1-2):1-19. [Medline].

  44. Lev R, Sweeney KG. Neutropenic enterocolitis. Two unusual cases with review of the literature. Arch Pathol Lab Med. 1993 May. 117(5):524-7. [Medline].

  45. Mulholland MW, Delaney JP. Neutropenic colitis and aplastic anemia: a new association. Ann Surg. 1983 Jan. 197(1):84-90. [Medline]. [Full Text].

  46. Nagler A, Pavel L, Naparstek E, Muggia-Sullam M, Slavin S. Typhlitis occurring in autologous bone marrow transplantation. Bone Marrow Transplant. 1992 Jan. 9(1):63-4. [Medline].

  47. Or R, Mehta J, Nagler A, Craciun I. Neutropenic enterocolitis associated with autologous bone marrow transplantation. Bone Marrow Transplant. 1992 May. 9(5):383-5. [Medline].

  48. Park YB, Lee JW, Cho BS, et al. Incidence and etiology of overt gastrointestinal bleeding in adult patients with aplastic anemia. Dig Dis Sci. 2010 Jan. 55(1):73-81. [Medline].

  49. Shaked A, Shinar E, Freund H. Neutropenic typhlitis. A plea for conservatism. Dis Colon Rectum. 1983 May. 26(5):351-2. [Medline].

  50. Sloas MM, Flynn PM, Kaste SC, Patrick CC. Typhlitis in children with cancer: a 30-year experience. Clin Infect Dis. 1993 Sep. 17(3):484-90. [Medline].

  51. Spencer SP, Power N, Reznek RH. Multidetector computed tomography of the acute abdomen in the immunocompromised host: a pictorial review. Curr Probl Diagn Radiol. 2009 Jul-Aug. 38(4):145-55. [Medline].

  52. Tiseo M, Gelsomino F, Bartolotti M, Barili MP, Ardizzoni A. Typhlitis during second-line chemotherapy with pemetrexed in non-small cell lung cancer (NSCLC): A case report. Lung Cancer. 2009 Aug. 65(2):251-3. [Medline].

  53. Weinberger M, Hollingsworth H, Feuerstein IM, Young NS, Pizzo PA. Successful surgical management of neutropenic enterocolitis in two patients with severe aplastic anemia. Case reports and review of the literature. Arch Intern Med. 1993 Jan 11. 153(1):107-13. [Medline].

 
Previous
Next
 
Ulcerative oral mucositis lesion on the lateral and ventral surfaces of the tongue.
Colonic pseudomembranes of pseudomembranous colitis. Photographs courtesy of Eric M. Osgard, MD.
Frontal abdominal radiograph in a patient with proved pseudomembranous colitis. Note the nodular haustral thickening, most pronounced in the transverse colon.
Perforated appendicitis with abscess; computed tomography scan. Note the appendicolith (arrow) and air within the abscess. The terminal ileum lies anterior to the appendiceal abscess, and inflammatory change is noted in its wall, which appears thickened (open arrow).
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.
Typhlitis. Marked asymmetric cecal wall thickening (arrow) in a 64-year-old patient whose status is postchemotherapeutic for lymphoma.
Typhlitis. Marked circumferential cecal and ascending colon wall thickening (large arrows) with mild pericolonic inflammatory stranding (small arrows).
 
 
 
All material on this website is protected by copyright, Copyright © 1994-2016 by WebMD LLC. This website also contains material copyrighted by 3rd parties.