Approach Considerations
The ongoing growth in chemotherapy for hematologic and solid-organ malignancies has resulted in increased neutropenia-related perianal and intra-abdominal infections. Joint management between medical and surgical teams is extremely important for a good outcome in patients with neutropenic enterocolitis. [30, 38]
Patients with neutropenic enterocolitis must be monitored in an intensive care unit (ICU) with serial abdominal examinations. Management of these patients often is not straightforward. A wide range of diagnostic and therapeutic approaches have been proposed for neutropenic enterocolitis. To date, most large-scale studies and recommendations on this condition have involved hematologic patients; they will require further validation in ICU patients. [39] A key determinant of infection resolution is the degree and duration of neutropenia.
Use of recombinant granulocyte colony-stimulating factor (GCSF) may be considered in individual patients, depending on the clinical progression. [11] Controlled trials using GCSF in this specific entity are lacking, although several case reports of a successful outcome have been reported in the literature. Moreover, a better understanding and definition of specific subsets of patients that may benefit from treatment or prevention of neutropenic enterocolitis is needed.
Medical Care
Although there are practice guidelines available, [40] no published randomized control trials comparing conservative medical therapy with surgical intervention in neutropenic enterocolitis exist; however, both types of therapy have their advocates.
The outcome appears to reflect the state of the underlying disease and other comorbidities at the time of the clinical presentation rather than the treatment modality. Accordingly, a uniform management strategy for neutropenic enterocolitis cannot be recommended. Individualize the approach to each patient. Early recognition of neutropenic enterocolitis in a patient who is neutropenic is paramount for achieving a good outcome.
Conservative management includes the following:
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Bowel rest and nasogastric suction
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Close monitoring of patients using serial abdominal examinations in an intensive care unit (ICU)
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Intravenous fluids, blood, and platelet transfusions as necessary
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Parenteral broad-spectrum antibiotics – Antibiotics should include agents covering enteric gram-negative and anaerobic organisms, including Clostridium and Enterococcus species, Enterobacteriaceae, and Pseudomonas aeruginosa [30] ; metronidazole may also be considered if pseudomembranous colitis cannot immediately be excluded
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Avoidance of certain medications – Anticholinergic agents, antidiarrheal drugs, and narcotics may worsen the condition or further confuse the clinical picture of neutropenic enterocolitis
Withhold further chemotherapy until complete recovery from neutropenic enterocolitis occurs.
Diet and activity
Because the patient is fasting and on bowel rest, consider parenteral nutrition. Patients with neutropenic enterocolitis are usually extremely ill and in the ICU on complete bed rest. [30]
Surgical Care
Immediate surgery was proposed by Shamberger et al in patients with neutropenic enterocolitis with the following indications [19] :
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Free intra-abdominal perforation
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Clinical deterioration during conservative medical therapy
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Differentiation from other acute abdominal conditions for which surgery is indicated
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Unrelenting intra-abdominal sepsis or abscess formation
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Continued hemorrhage with a platelet count and coagulation parameters within the reference range
Tailor the surgical procedure to the operative findings.
Surgical options include the following:
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Cecostomy and drainage
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Two-stage right hemicolectomy or total abdominal colectomy, with or without a primary anastomosis
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Defunctioning of the colon with a loop ileostomy
Normal-appearing serosal surfaces may conceal mucosal breakdown and necrosis. Therefore, resection should be extensive to assure removal of the diseased bowel.
Consider elective right hemicolectomy in patients who have required repeated courses of chemotherapy and who have responded to initial conservative medical therapy. Recurrent episodes of neutropenic enterocolitis have been reported in such patients.
Prevention
Consider antibiotic prophylaxis in neutropenic patients. A meta-analysis by Gafter-Gvili suggested an overall mortality benefit with antibiotic prophylaxis, although this is not specific to neutropenic enterocolitis. [42] Another meta-analysis suggested a mortality benefit in primary prophylaxis with granulocyte colony-stimulating factors (GCSFs) in adult cancer patients, but it was also not specific to neutropenic enterocolitis. [43]
Consider an elective right hemicolectomy in patients with neutropenic enterocolitis who have successfully recovered and may require repeated courses of chemotherapy in the near future. [1]
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Neutropenic enterocolitis. Ulcerative oral mucositis lesion on the lateral and ventral surfaces of the tongue.
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Neutropenic enterocolitis. Colonic pseudomembranes of pseudomembranous colitis. Photographs courtesy of Eric M. Osgard, MD.
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Neutropenic enterocolitis. Frontal abdominal radiograph in a patient with proved pseudomembranous colitis. Note the nodular haustral thickening, most pronounced in the transverse colon.
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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).
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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.
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Typhlitis. Marked asymmetric cecal wall thickening (arrow) in a 64-year-old patient whose status is postchemotherapy for lymphoma.
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Typhlitis. Marked circumferential cecal and ascending colon wall thickening (large arrows) with mild pericolonic inflammatory stranding (small arrows).
