Download Typhlitis

By
Hana’a Tashkandi
Surgical Demonstrator
KAAU
Typhlitis
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Definition
Epidemiology
Pathophysiology
Clinical presentation
Complications
D.D.
Investigations
Management
Prognosis
What does it mean?
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Typhlitis means inflammation of the cecum.
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It is an acute life-threatening condition
characterized by transmural inflammation
involving ileum, cecum, or appendix in
patients who are severely myelosuppressed
and immunosuppressed.
What does It Mean?
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Associated with:
Aplastic anemia.
Lymphoma.
AIDS.
Immunosuppression following renal
transplantation or during treatment of
malignancy.
Epidemiology
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found in 10% of leukemic children who died while
undergoing chemotherapy.
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mortality rate averages 40-50% (cecal perforation,
bowel necrosis, or sepsis).
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Prevalence is equal in males and females.
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Typhlitis occurs in both children and adults.
Pathophysiology
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The etiology of typhlitis is unknown but pathogenesis
is multifactorail.
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Profound neutropenia, with total neutrophil counts of
less than 1000 appears to be a universal predisposing
factor.
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Mucosal injury from cytotoxic drugs plays an
important role in the typhlitis observed during
chemotherapy.
Pathophysiology
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Cecal distension in typhlitis may impair the blood supply,
leading to mucosal ischemia and ulceration.
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Infection may be involved, especially cytomegalovirus.
Bacterial invasion leads to transmural penetration and
ultimately perforation.
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Mucosal and submucosal necrosis can result in intramural
hemorrhage.
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Neoplastic infiltration may be involved in some patients.
Clinical Manifestations
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Watery or bloody diarrhea
Fever
Nausea
Vomiting
Abdominal pain (may be localized to right
lower quadrant)
Possible shock secondary to septicemia or
colonic perforation
Clinical Findings
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Abdominal distension
Palpation tenderness (usually most marked in
RLQ)
Occasionally, a palpable mass
Diffuse direct and rebound tenderness
(suggesting colonic perforation, peritonitis)
Hyper-resonant abdomen
Absence of bowel sounds
D.D.
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Acute Appendicitis.
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I.B.D.
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Enterocolitis.
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Toxic Megacolon.
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Small bowel obstruction.
Complications
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Bowel perforation and peritonitis
Gastrointestinal bleeding
Gastrointestinal obstruction
Intra-abdominal abscess
Sepsis
Death
Investigations
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Complete blood count is used to confirm
neutropenia.
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Stool studies are obtained for the following:
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Clostridium difficile toxin to rule out
pseudomembranous colitis.
Culture for enteric pathogens to rule out infectious
causes of enterocolitis.
Investigations
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AXR:
Plain radiographs are nonspecific but may
demonstrate a fluid-filled masslike density in
the RLQ, distension of adjacent small bowel
loops, and thumbprinting. Free intraperitoneal
air and pneumatosis coli rarely are observed.
Barium enema and colonoscopy are
contraindicated in possible typhlitis because of
perforation risk.
Investigations
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CT Abdomen:
CT demonstrates circumferential and occasionally
eccentric low-attenuation colonic wall thickening and
cecal distension. High attenuation within the
thickened colonic wall may represent hemorrhage.
Inflammatory pericolonic stranding of mesenteric fat
is common.
CT readily identifies complications, including
pneumatosis coli, pneumoperitoneum, pericolonic
fluid collections, and abscess. These complications
may require urgent surgical management.
Management
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Conservative
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Surgical
Management
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Conservative management includes the following:
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Bowel rest and nasogastric suction
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Close monitoring of patients using serial abdominal
examinations in an intensive care setting
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Intravenous fluids, blood, and platelet transfusions as
necessary
Management
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Parenteral broad-spectrum antibiotics: Antibiotics
should include agents covering enteric gramnegative and anaerobic organisms, including
Clostridium species. Metronidazole also may be
considered if pseudomembranous colitis cannot
immediately be excluded.
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Cultures: Obtain blood cultures for fungus and
consider antifungal agents if patients do not
respond to antibiotics.
Management
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Avoidance of certain medications: Anticholinergic
agents, antidiarrheal drugs, and narcotics may
worsen the condition or further confuse the clinical
picture.
Surgical Management
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indications:
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Free intra-abdominal perforation
Clinical deterioration during conservative medical
therapy
Differentiation from other acute abdominal
conditions for which surgery is indicated
Unrelenting intra-abdominal sepsis or abscess
formation
Continued hemorrhage with a platelet count and
coagulation parameters within the reference range
Surgical Management
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Choice of surgical procedures includes the
following:
1) Cecostomy and drainage
2) A 2-stage right hemicolectomy or
total abdominal colectomy, with or
without a primary anastomosis
3) Defunctioning of the colon with a
loop ileostomy
Prognosis
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The prognosis generally is poor, with mortality
rates varying from 5-100% and averaging
about 40-50%.
The prognosis depends highly on the rapidity
of restoration of the white blood cell count.
The potential for recovery may be improved
by aggressive and meticulous medical and
supportive therapy.
Summary
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Consider the possibility of neutropenic enterocolitis
in all patients who are immunosuppressed and have
right lower quadrant pain.
Early recognition of this condition is paramount to
reducing mortality rates and achieving a potentially
good outcome.
Monitor the patient in an intensive care setting with
frequent serial abdominal examinations.
Joint management by the medical and surgical teams
is essential for optimal management.
Thank You
Hana’a Tashkandi