Typhlitis

Typhlitis

We all care for many children who present with fever, nausea, and vomiting.  Naturally, one of our first goals is to consider severe and life-threatening conditions and, fortunately, many times these are apparent on clinical exam.  Unfortunately, certain patient populations, especially the pediatric oncology patient, may present with nonspecific symptoms and have a nonspecific exam but end up having a very specific and significant condition: Typhlitis.

Typhlitis Basics:

  • Necrotizing inflammation of the colon, cecum, and / or terminal part of the ileum.
  • Also known as “Neutropenic colitis” (although the patient does not have to be strictly neutropenic).
  • Associated with:
    • Underlying Malignancy
    • Intensive Chemotherapy
    • Severe Neutropenia
  • Incidence = 0.35% to 10% of children with malignancies (depending on the study).
  • In recent years, with the use of more intensive chemotherapy regimens, there has been an increase in incidence of typhlitis.

 

Dangers of Typhlitis:

  • May progress to full thickens necrosis and Bowel Perforation! {that’s suboptimal}
  • May lead to intestinal hemorrhage. {also subpar}
  • The injured intestine may act as an entry point for bacteria to transmigrate into bloodstream and lead to Sepsis. {nuff said}
  • Mortality rates of Typhlitis range from 2.2% to 48%.

 

Causes of Typhlitis:

  • Strictly speaking, it is not fully known.
  • Suspected culprits:
    • Drug-induced GI ulcerations
    • Neutropenia leading to invasive bacteria related mucosa damage
    • Sepsis-induced hypotension leading to bowel ischemia
    • Combination of all…

 

Typhlitis Presentation:

  • Initially, the presenting symptoms can be very nonspecific:
    • Crampy Abdominal Pain
    • Diarrhea
    • Nausea
    • Vomiting
    • Right Lower Quadrant Pain
    • Fever
  • The “Classic Triad” — unfortunately, “Classic” doesn’t mean Definitive.
    1. Abdominal Pain -absent in 9% in one study
    2. Fever – absent in 16% in one study
    3. Neutropenia – absent in 12% in one study

 

Typhlitis Increased Risk Factors:

  • Having received chemotherapy in previous 2 weeks.
  • Pt with mucositis on exam.
  • S/P Stem Cell Transplantation.
  • Certain drug regimens confer greater risk (but I can’t pronounce them, so I’d recommend discussing with the pt’s oncologist).

 

Imaging for Typhlitis:

  • Ideal imaging modality is still debated… and likely dependent upon your institutional resources.
  • Abdominal X-Ray
    • May show small bowel obstruction
    • May show fluid-filled cecum
    • More useful to look for Free-air and Air-fluid levels.
  • Abdominal CT
    • Pro: can help differentiate other abdominal pathology.
    • Con: Radiation, Bowel Wall thickness does not correlate with severity of typhlitis.
  • Abdominal U/S
    • Pro: no Radiation. Pt’s tolerate well. The degree of Bowel Wall Thickening has been correlated with severity of disease.
    • Con: Operator dependent (so need good institutional experience). Need to evaluate the length of the colon… not just RLQ.

 

Therapy for Typhlitis:

  • Generally, conservative management is successful, when detected early in the course of the condition.
    • NPO
    • IVF
    • Broad Spectrum Antibiotics (ex:…)
      • Ceftazidime
      • Meropenem
      • Pip/Tazo
      • Metronidazole
  • Surgical intervention should be used for bowel perforation, persistent GIB, or clinical deterioration despite optimal medical management.

 

 Altinel E, et al. Typhlitis in Acute Childhood Leukemia. Med Princ Pract 2012; 21:36-39.

Moran H, et al. Risk Factors for Typhlitis in Pediatric Patients with Cancer. J Pediatr Hematol Oncol 2009;31:630-634.

McCarville MB, et al. Typhlitis in Childhood Cancer. Cancer 2005;104(2):380-387.

 

Sean Fox

I enjoy taking care of patients and I finding it endlessly rewarding to help train others to do the same. I trained at the Combined Emergency Medicine and Pediatrics residency program at University of Maryland, where I had the tremendous fortune of learning from world renown educators and clinicians. Now I have the unbelievable honor of working with an unbelievably gifted group of practitioners at Carolinas Medical Center. I strive every day to inspire my residents as much as they inspire me.

You may also like...

1 Response

  1. August 15, 2015

    […] Typhlitis (neutropenic enterocolitis) – […]

Leave a Reply

Your email address will not be published. Required fields are marked *