History

Most patients who are affected with neutropenic enterocolitis are receiving antineoplastic drugs and are profoundly neutropenic (ie, < 1000 cells/μL).

The time course and severity of the clinical presentation of neutropenic enterocolitis is variable. Symptoms usually occur within 10-14 days after the initiation of cytotoxic chemotherapy. The typical presentation mimics that of acute appendicitis.

Symptoms include the following:

Right-lower-quadrant abdominal pain, which may be cramping and intermittent or a continuous dull ache
Fever
Watery or bloody diarrhea, ^[23]which occurs in about 25-45% of patients
Nausea
Vomiting
Abdominal distention

Oral and pharyngeal mucositis (see the image below) may manifest before the onset of colonic symptoms

Neutropenic enterocolitis. Ulcerative oral mucositis lesion on the lateral and ventral surfaces of the tongue.

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Physical Examination

Physical findings in patients with neutropenic enterocolitis vary according to the severity of the disease and the presence or absence of complications. The following may be noted:

Abdominal distention, hypoactive bowel sounds, and a tympanitic abdomen may suggest ileus
The abdomen may be markedly tender, especially in the right lower quadrant
The cecum may be palpated as a boggy mass
Rebound tenderness and rigidity may suggest colonic perforation
Shock may be present as a consequence of sepsis

Differential Diagnoses

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Media Gallery

Neutropenic enterocolitis. Ulcerative oral mucositis lesion on the lateral and ventral surfaces of the tongue.
Neutropenic enterocolitis. Colonic pseudomembranes of pseudomembranous colitis. Photographs courtesy of Eric M. Osgard, MD.
Neutropenic enterocolitis. Frontal abdominal radiograph in a patient with proved pseudomembranous colitis. Note the nodular haustral thickening, most pronounced in the transverse colon.
Neutropenic enterocolitis. 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).
Neutropenic enterocolitis. Plain abdominal radiograph in a 44-year-old man known to have a 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 postchemotherapy for lymphoma.
Typhlitis. Marked circumferential cecal and ascending colon wall thickening (large arrows) with mild pericolonic inflammatory stranding (small arrows).

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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, American Gastroenterological Association, American Society for Gastrointestinal Endoscopy, Columbia Medical Society, South Carolina Gastroenterology Association, 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.

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

Neutropenic Enterocolitis Clinical Presentation

History

Physical Examination

References

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