What is the appropriate management for a patient diagnosed with Typhlitis?

Management of Typhlitis (Neutropenic Enterocolitis)

The primary management of typhlitis is conservative with immediate broad-spectrum antibiotics, bowel rest, and supportive care, reserving surgery exclusively for perforation, bowel ischemia, persistent hemorrhage, or clinical deterioration despite medical therapy. 1

Initial Conservative Management (First-Line for All Patients)

Immediate antibiotic therapy is mandatory once diagnosis is confirmed:

• Monotherapy with anti-pseudomonal β-lactam agent (piperacillin-tazobactam) OR carbapenem (meropenem) as first-line per IDSA guidelines for febrile neutropenia 1, 2
• Add additional antimicrobials only if no clinical improvement occurs or specific infection focus is suspected 1
• Antifungal therapy is NOT indicated initially but may be added if fever persists despite antibiotics 1

Bowel rest is mandatory in all cases:

• Complete bowel rest with nasogastric suction 1, 2, 3
• Total parenteral nutrition for nutritional support 1, 3
• Avoid laxatives and antidiarrheal agents 3

Supportive measures:

• Intravenous fluid resuscitation 1
• Granulocyte colony-stimulating factors (G-CSF) to normalize neutrophil counts—resolution directly correlates with neutrophil recovery 1, 2

Expected outcomes: Up to 86% of patients achieve resolution with conservative treatment in a median of 6-8 days 1, 2

Imaging-Based Risk Stratification

CT scan is the gold standard for diagnosis and prognosis 1:

• Bowel wall thickening >10mm carries 60% mortality risk versus 4.2% if <10mm 1, 4
• Overall mortality with positive radiologic signs reaches 29.5% 1, 5

High-risk ultrasound findings requiring intensive monitoring 1:

• Fluid-filled bowel
• Ascites or free fluid between bowel loops
• Hyperechoic septa floating in bowel lumen (representing necrotic mucosa)

Serial imaging is essential to detect abscess formation, perforation, or clinical deterioration 1

Absolute Indications for Emergency Surgery

Surgery must be performed immediately for 1, 4:

• Perforation (free or contained)
• Bowel ischemia or necrosis
• Persistent gastrointestinal bleeding after resolution of neutropenia and correction of coagulopathy
• Clinical deterioration requiring vasopressors or suggesting uncontrolled sepsis
• Abscess formation not amenable to percutaneous drainage

Surgical approach:

• Damage control surgery in severely sick patients with physiological derangement 1, 4
• Right hemicolectomy with resection of all necrotic tissue 3
• Ileostomy and mucous fistula (Hartmann-type procedure) preferred in critically ill patients 4, 3
• Failure to remove necrotic focus is universally fatal 4, 3

Critical Pitfalls and Caveats

Clinical presentation may be deceptively mild despite catastrophic pathology:

• Neutropenic patients lack inflammatory response, so peritoneal signs may be minimal or absent 2, 5
• Maintain high index of suspicion and rely heavily on imaging rather than physical examination 1

Surgical mortality is extremely high but necessary when indicated:

• Emergency surgery mortality: 57-81% in patients on recent chemotherapy 1, 4
• However, perforation without surgery is universally fatal 4
• Do NOT delay surgery waiting for hematologic recovery when absolute indications are present 4

Colonoscopy is absolutely contraindicated due to very high perforation risk 1

Monitor for concurrent infections:

• Consider Clostridioides difficile testing in all cases 1, 6
• Multiple pathogens may coexist in immunosuppressed patients 1

Monitoring and Follow-Up

Frequent clinical reassessment is mandatory:

• Serial abdominal examinations every 4-6 hours in hospitalized patients 1
• Early surgical consultation even for conservatively managed cases 1
• Repeat imaging if clinical deterioration or no improvement within 48-72 hours 1

Resolution indicators:

• Rising neutrophil count directly correlates with symptom resolution 1, 2
• Clinical improvement typically occurs within 6-8 days of appropriate therapy 1, 2