What is the management approach for typhilitis?

Management of Typhlitis (Neutropenic Enterocolitis)

The management of typhlitis requires a combination of aggressive medical therapy with selective surgical intervention based on specific clinical criteria, with bowel rest and broad-spectrum antibiotics forming the cornerstone of initial treatment.

Definition and Clinical Presentation

• Typhlitis (neutropenic enterocolitis) is a life-threatening necrotizing process primarily affecting the cecum, terminal ileum, and ascending colon in neutropenic patients 1, 2
• Common presenting symptoms include fever, abdominal pain (particularly in right lower quadrant), abdominal distension, watery or bloody diarrhea, and nausea during periods of severe neutropenia 1, 3
• The condition is most commonly seen in patients with acute myelogenous leukemia receiving intensive chemotherapy, particularly high-dose cytosine arabinoside 1, 4

Diagnosis

• Diagnosis is confirmed through serial abdominal examinations and imaging studies including:
  • Abdominal radiographs
  • Ultrasonography
  • Computed tomography (CT)
  • Radionuclide scans 1
• CT findings typically show cecal wall thickening, pericolonic inflammation, and may demonstrate pneumatosis intestinalis in severe cases 3
• Blood cultures should be obtained, as bacteremia with intestinal flora is common 4

Medical Management

• First-line treatment consists of complete bowel rest with nasogastric suction and total parenteral nutrition 1, 4
• Broad-spectrum combination antibiotics with coverage against gram-negative, gram-positive, and anaerobic organisms are essential 1, 3
• Avoid laxatives and antidiarrheal agents which may worsen the condition 1
• Granulocyte support may be beneficial in selected cases 1
• Monitor for resolution of symptoms, which typically corresponds with recovery of neutrophil counts 5
• For patients with a history of typhlitis who require further chemotherapy, prophylactic bowel rest and total parenteral nutrition should be instituted at the beginning of treatment 1

Surgical Management

• Surgical intervention is indicated in patients meeting any of the following criteria:
  1. Persistent gastrointestinal bleeding after resolution of neutropenia and thrombocytopenia
  2. Evidence of free intraperitoneal perforation
  3. Clinical deterioration requiring vasopressor support or large fluid volumes suggesting uncontrolled sepsis
  4. Development of symptoms of an intra-abdominal process in the absence of neutropenia that would normally require surgery 4
• The surgical approach typically involves:
  • Resection of all necrotic material, usually by right hemicolectomy
  • Creation of ileostomy and mucous fistula rather than primary anastomosis
  • Complete removal of the necrotic focus is essential, as failure to do so is fatal in these immunocompromised patients 1, 2

Special Considerations

• Concomitant infections such as Clostridium difficile colitis may occur and should be treated appropriately 3
• Typhlitis can occur in other immunocompromised states beyond neutropenia from chemotherapy, including common variable immunodeficiency 5
• The mortality rate has historically been high (50-100%), but with early recognition and appropriate management, outcomes can be significantly improved 4
• Recurrence of typhlitis with subsequent chemotherapy cycles is possible, particularly if symptoms occurred during initial induction 4

Prevention

• For patients with a history of typhlitis or nonspecific gastrointestinal complaints during chemotherapy:
  • Consider prophylactic bowel rest
  • Implement total parenteral nutrition at the beginning of subsequent chemotherapy cycles 1
• Early recognition of precipitating factors and timely intervention can reduce the incidence of complications 1