What is the treatment for typhlitis (inflammation of the cecum) complicated by perforation and microabscess?

Treatment of Typhlitis Complicated by Perforation and Microabscess

For typhlitis with perforation and microabscess, emergency surgical intervention is mandatory, as these complications represent absolute indications for surgery despite the high operative mortality in neutropenic patients. 1

Immediate Surgical Indications

Perforation is an absolute indication for surgery in typhlitis, overriding the general preference for conservative management. 1 The presence of microabscess formation alongside perforation represents a surgical emergency requiring source control. 1

Surgical Approach

• Damage control surgery should be adopted in severely sick patients with physiological derangement, which is typical in perforated typhlitis. 1

• Two-stage procedures are strongly preferred over primary anastomosis in this setting, given the unprepared bowel, severe illness, and neutropenic state. 2

• Surgical options include:

  • Resection of necrotic bowel with stoma creation (Hartmann-type procedure preferred in critically ill patients) 1
  • Cecostomy and drainage if hematologic recovery has occurred and necrosis is limited 3
  • Right hemicolectomy only if widespread necrosis is present 3

Critical Context: Why Surgery Despite High Risk

The mortality for emergency surgery in neutropenic patients is sobering—up to 81% for patients on active chemotherapy, and 57% for those who had chemotherapy within 30 days. 1 However, perforation without surgical intervention is universally fatal. 1

Bowel wall thickening >10mm on CT carries a 60% mortality risk, and the presence of perforation with microabscess indicates advanced disease requiring source control. 1

Antibiotic Therapy

Initial Empiric Coverage

Immediate broad-spectrum antibiotics covering Gram-negative bacteria and anaerobes must be initiated before and continued after surgery. 1, 4

First-line regimen per IDSA guidelines for febrile neutropenia:

• Anti-pseudomonal β-lactam agent (piperacillin-tazobactam 4g/0.5g q6h) 1
• OR carbapenem (meropenem 1g q6h by extended infusion) 1

Duration of Antibiotics

• 4 days if adequate source control is achieved in immunocompetent patients 1
• Up to 7 days in immunocompromised or critically ill patients based on clinical response and inflammatory markers 1
• Continue beyond 7 days only if ongoing signs of infection persist, warranting diagnostic re-evaluation rather than empiric prolongation 1

Adjunctive Management

• Bowel rest is mandatory 1, 4
• Intravenous fluids and total parenteral nutrition 1, 5
• Normalization of neutrophil counts through granulocyte colony-stimulating factors correlates directly with resolution 1
• Percutaneous drainage of accessible abscesses may be considered as adjunct to surgery if collections are well-defined and accessible 1

Critical Pitfalls to Avoid

Do not delay surgery waiting for hematologic recovery when perforation is present—this is universally fatal. 1 The only exception is if cecostomy/drainage can be deferred until neutrophil recovery in cases of contained perforation without diffuse peritonitis, but this is rarely feasible. 3

Do not perform primary anastomosis in this setting—the combination of unprepared bowel, neutropenia, severe sepsis, and friable tissue makes anastomotic leak nearly inevitable. 2, 1

Clinical signs may be minimal or absent despite catastrophic intra-abdominal pathology due to neutropenia—maintain high suspicion and rely on imaging. 1

Mortality reaches 29.5% even with appropriate treatment when radiologic signs of typhlitis are present, and approaches 60% with bowel wall >10mm. 1 Perforation with microabscess represents the most severe end of this spectrum, requiring aggressive intervention despite poor prognosis.