What is the diagnosis and treatment for neutropenic (having an abnormally low number of neutrophils, a type of white blood cell) enterocolitis (inflammation of the small intestine and colon)?

From the Guidelines

Neutropenic enterocolitis should be managed with immediate hospitalization, bowel rest, intravenous fluids, broad-spectrum antibiotics, and pain control, with surgical consultation reserved for complications such as perforation, uncontrolled sepsis, or persistent bleeding, as recommended by the most recent guidelines 1.

Key Management Principles

• Immediate hospitalization and bowel rest with nothing by mouth
• Intravenous fluids for hydration
• Broad-spectrum antibiotics, such as piperacillin-tazobactam 4.5g IV every 6 hours or meropenem 1g IV every 8 hours plus metronidazole 500mg IV every 8 hours, to cover enteric gram-negative organisms, gram-positive organisms, and anaerobes 1
• Pain control and nasogastric tube decompression as needed
• Serial abdominal examinations and imaging (CT scans) to monitor disease progression
• Surgical consultation for potential complications, with indications for surgery including persistent gastrointestinal bleeding, evidence of free intraperitoneal perforation, abscess formation, clinical deterioration, or need to rule out other intra-abdominal processes 1

Antibiotic Therapy

• Empirical antibiotic approach in neutropenic fever and/or infections, with consideration of antifungal therapy if no clinical improvement is observed 1
• Antibiotics should be continued for at least 10-14 days or until complete resolution of symptoms

Supportive Care

• Granulocyte colony-stimulating factors (G-CSF) like filgrastim at 5-10 mcg/kg/day subcutaneously to help recover neutrophil counts
• Blood transfusions may be necessary due to bloody diarrhea
• Anticholinergic, antidiarrheal, and opioid agents should be avoided as they may aggravate ileus 1

Prognosis and Mortality

• Mortality rates range from 30-50%, emphasizing the need for prompt recognition and aggressive treatment
• Clinical improvement and neutrophil count recovery (ANC >500/mm³) are crucial for a favorable outcome, with diet gradually advanced and antibiotics continued until complete resolution of symptoms 1

From the Research

Definition and Characteristics of Neutropenic Enterocolitis

• Neutropenic enterocolitis is a life-threatening gastrointestinal (GI) complication of chemotherapy, most often associated with leukemia or lymphoma 2, 3.
• It is characterized by an inflammatory process involving the colon and/or small bowel, which can result in ischemia, necrosis, bacteremia, hemorrhage, and perforation 4.
• The classic clinical features include fever and abdominal pain, with presenting signs and symptoms also possibly including nausea, vomiting, and diarrhea 5.

Diagnosis of Neutropenic Enterocolitis

• The diagnosis is supported by the findings of bowel wall thickening on ultrasonography or CT imaging 4, 3.
• Neutropenic patients with fever and abdominal symptoms should undergo evaluation of the abdomen for bowel wall thickening of >4 mm, the hallmark of neutropenic enterocolitis 3.
• Clostridium difficile infection should be ruled out, as well as other etiologies such as graft-versus-host disease 3.

Management of Neutropenic Enterocolitis

• The management of neutropenic enterocolitis is controversial, with no prospective or high-quality retrospective studies concerning medical or surgical therapies available 2, 4.
• Most authors recommend initial conservative management with bowel rest, intravenous fluids, total parenteral nutrition, broad-spectrum antibiotics, and normalization of neutrophil counts 2, 4, 3.
• Surgical intervention is recommended in the setting of obstruction, perforation, persistent gastrointestinal bleeding despite correction of thrombocytopenia and coagulopathy, and clinical deterioration 2, 4, 3.
• Surgical intervention may be necessary to manage complications such as hemorrhage and perforation and should be delayed, if possible, until recovery from neutropenia 3.

Outcomes and Prognosis

• The mortality rate for neutropenic enterocolitis is significant, with a reported mortality rate of 31% in medically managed cases and 23% in cases requiring surgical intervention 6.
• Early recognition and treatment are essential for survival, with rapid identification and timely, aggressive medical and/or surgical intervention being the cornerstones of survival for these patients 5.