What is the diagnosis and treatment for Typhlitis (Neutropenic enterocolitis)?

From the Guidelines

Neutropenic enterocolitis, also known as typhlitis, is a life-threatening condition that requires immediate medical attention and hospitalization, with the recommended management including bowel rest, intravenous fluids, broad-spectrum antibiotics, and close monitoring of vital signs and abdominal symptoms, as outlined in the most recent guidelines from the World Journal of Emergency Surgery 1. The diagnosis of neutropenic enterocolitis is based on the presence of neutropenia, bowel wall thickening on radiographic imaging, and the exclusion of other diagnoses, with CT scanning being the preferred imaging modality 1. Key aspects of management include:

• Bowel rest: Nothing by mouth (NPO)
• Intravenous fluids for hydration
• Broad-spectrum antibiotics:
  • Piperacillin-tazobactam 4.5g IV every 6 hours, or
  • Meropenem 1g IV every 8 hours
  • Add vancomycin 15-20 mg/kg IV every 12 hours if MRSA is suspected
• Pain management: Morphine or hydromorphone as needed
• Close monitoring of vital signs and abdominal symptoms
• Serial abdominal imaging (CT or ultrasound) to assess disease progression Avoid antidiarrheal medications and rectal examinations, as these can worsen the condition, as noted in the guidelines from the Annals of Oncology 1. Surgical intervention is reserved for cases with perforation, uncontrolled bleeding, or clinical deterioration despite medical management, with the goal of removing necrotic tissue and preventing further complications, as emphasized in the World Journal of Emergency Surgery guidelines 1. The condition typically occurs in patients undergoing chemotherapy for hematologic malignancies, resulting in severe neutropenia and mucosal damage to the intestinal wall, allowing bacterial translocation and inflammation, leading to the characteristic symptoms of abdominal pain, fever, and diarrhea, as described in the Annals of Oncology guidelines 1. Granulocyte colony-stimulating factor (G-CSF) may be considered to help resolve neutropenia faster, and blood transfusions may be necessary in cases of bloody diarrhea, as noted in the guidelines from the Annals of Oncology 1. Overall, the management of neutropenic enterocolitis requires a multidisciplinary approach, with close collaboration between medical and surgical teams, to optimize outcomes and minimize morbidity and mortality, as emphasized in the World Journal of Emergency Surgery guidelines 1.

From the Research

Diagnosis of Typhlitis (Neutropenic Enterocolitis)

• The diagnosis of typhlitis (neutropenic enterocolitis) is based on the presence of an absolute neutrophil count <1000/mm, compatible abdominal symptoms, and either mucosal thickening on abdominal imaging or mucosal injury on colon biopsy 2.
• Presenting signs and symptoms may include fever, abdominal pain, nausea, vomiting, and diarrhea 3, 4.
• Neutropenic enterocolitis must be considered a diagnosis of exclusion, and care of these patients should be individualized 5.

Treatment of Typhlitis (Neutropenic Enterocolitis)

• The management of neutropenic enterocolitis is controversial, and a uniform management strategy cannot be recommended 6.
• Early management should be conservative and consist of bowel rest, intravenous fluid administration, total parenteral nutrition, broad-spectrum antibiotics, and normalization of neutrophil counts 6, 5.
• Surgical intervention is warranted in the setting of perforation, obstruction, clinical deterioration suggestive of uncontrolled sepsis, and persistent GI bleeding despite correction of cytopenias and coagulopathy 6, 5.
• The use of granulocyte colony-stimulating factor can be beneficial to shorten the duration of neutropenia 2.
• Prompt diagnosis and management of neutropenic enterocolitis are critical to prevent complications 2.

Complications and Outcomes

• Complications of neutropenic enterocolitis include sepsis, colonic perforation, pneumatosis intestinalis, and abscess formation 2.
• The risks associated with complications include immunosuppressive therapy use within 1 month before neutropenic enterocolitis onset, delayed imaging, older age, severe neutropenia, prolonged neutropenia before and after neutropenic enterocolitis diagnosis, and other concomitant systemic infections 2.
• Older age, severe neutropenia, prolonged neutropenia before and after neutropenic enterocolitis diagnosis, and other concomitant systemic infections are associated with lower survival rates 2.