The medical and surgical management of typhlitis in children with acute nonlymphocytic (myelogenous) leukemia

Citrobacter freundii and fatal neutropenic enterocolitis following adjuvant chemotherapy for breast cancer

Neutropenic enterocolitis is increasingly being recognized as a life-threatening complication of chemotherapy, mainly for haematological and lymphoproliferative malignancies. It is under-recognized clinically, with the diagnosis often being made on post-mortem examination. Although active medical management is generally preferred, surgical intervention may be indicated. We report a case of fatal neutropenic enterocolitis, secondary to Citrobacter freundii, following adjuvant chemotherapy for breast cancer. We also review the literature, examining the aetiology, diagnosis and management of this often fatal entity.

Plain radiography for diagnosis of gastrointestinal perforation in immune-compromised children--is it enough?

Gastrointestinal perforation is a surgical emergency in the pediatric patient and any delay in diagnosis might be hazardous. In immunocompromised children, the clinical signs of perforation may be blunted. We describe a child with acute lymphoblastic leukemia (ALL) and a perforated appendix and ileum in whom computerized tomography (CT) revealed extraluminal air that was not initially identified on plain abdominal film. Our case demonstrates the importance of early abdominal CT and ultrasound examination in detecting these potentially lethal complications.

Toxic megacolon complicating chemotherapy for acute myeloid leukaemia

A 43 year old woman in remission from acute myeloid leukaemia developed abdominal pain, severe melaena, diarrhoea and gram-negative septicaemia whilst severely pancytopenic following consolidation chemotherapy. Subsequently, serial abdominal X-rays showed a progressive toxic megacolon. Conservative management was attempted but, because of radiological evidence of increasing colonic dilatation and incipient perforation, an emergency defunctioning colostomy was performed. The patient recovered and 2 months later the caecostomy was reversed and a right hemicolectomy performed. This first described case of toxic megacolon following leukaemia treatment is compared with three previously described cases following cytotoxic chemotherapy for other conditions.

Indications for surgical intervention for gastrointestinal emergencies in children receiving chemotherapy

BACKGROUND

Abdominal pain in children receiving chemotherapy for cancer presents the clinician with unique problems due to the altered immunity of these patients or to the oncologic setting. The major clinical decisions regarding these patients are to determine if and when operative intervention is indicated.

METHODS

A retrospective study was done to examine the clinical, radiographic, and laboratory findings that indicate the need for surgical intervention. Sixty-eight of 1090 children who underwent treatment for cancer from October 1982 to December 1990 developed abdominal complaints requiring them to be hospitalized. Nineteen of these patients underwent exploratory laparotomy (operative), and the other 49 were observed (nonoperative).

RESULTS

No significant differences were observed in the phase of chemotherapy, treatment with vincristine or corticosteroids, or the hematologic indices between the operative and nonoperative groups. Eighteen of nineteen patients survived their surgeries. Seventeen (89%) of these laparotomies were positive based on the surgical pathology and the operative report. Peritoneal signs on physical examination (P < 0.001) or pneumatosis intestinalis on abdominal radiographs correlated with positive laparotomies (P = 0.001).

CONCLUSIONS

Peritoneal signs on physical examination or pneumatosis intestinalis on abdominal X-rays were associated with and specific for the presence of acute surgical disease of the abdomen in immunocompromised pediatric oncology patients.

Collagenous colitis, eosinophilic colitis, and neutropenic colitis

Neutropenic colitis is a complication of the treatment of hematologic malignancies and, less commonly, of other disease entities. The septic, inflammatory process has a predilection for the terminal ileum and right colon. While the pathogenesis is not clear, mucosal injury caused by several different mechanisms and local opportunistic infection play significant roles. An association has been recognized between neutropenic colitis and sepsis caused by C. septicum. Patients present with fever, diarrhea, and acute abdominal pain and tenderness often localized in the right lower quadrant. Sonography and CT are helpful in demonstrating colonic wall thickening and pericolic fluid. Peritoneal lavage has been used to exclude perforation in these critically ill patients. Although there has been debate about whether medical or operative management is best, the optimal initial therapy includes supportive care with gastric decompression, fluid and blood product replacement, and broad-spectrum antibiotics. The indications for surgery include continued intestinal bleeding despite correction of coagulopathy and pancytopenia, free intraperitoneal air, and uncontrolled sepsis. At operation, a right colectomy with ileostomy and mucous fistula or, in selected patients, primary anastomosis is the procedure of choice. Timely return of functioning neutrophils and the eventual prognosis of the primary disease are crucial to the overall success or failure of treatment of neutropenic colitis.

Typhlitis resulting from treatment with taxol and doxorubicin in patients with metastatic breast cancer

BACKGROUND

Typhlitis is being recognized with increasing frequency as a serious complication of aggressive chemotherapy for hematologic and solid malignancies.

METHODS

In this report the authors describe two cases of typhlitis in patients with metastatic breast cancer treated with taxol and doxorubicin.

RESULTS

Both cases occurred during the first cycle of treatment with taxol (180 mg/m2) and doxorubicin (75 mg/m2), being given simultaneously as 72-hour continuous intravenous infusions.

CONCLUSION

Two cases of typhlitis have occurred after combined treatment with taxol and doxorubicin, while typhlitis has not been described after treatment with either drug alone.

Acute appendicitis in children with leukemia and other malignancies: still a diagnostic dilemma

Of 6,099 children treated for malignancy, 16 (ages 3.5 to 18 years) developed acute appendicitis between 1962 and 1989. Fourteen had leukemia (ALL 10, AML 4). One each had rhabdomyosarcoma and Ewing's sarcoma. Active malignancy at diagnosis was noted in 10, 4 of whom had severe neutropenia (absolute neutrophil count less than 500/mm3). Of all the leukemics (2,794/6,099), abdominal pain during induction was a frequent complaint. The incidence of appendicitis, however, was low (0.5%). Nine of the 16 patients presented classically, facilitating prompt diagnosis and treatment. Six diagnoses were delayed. Three of these patients presented atypically with vague, nonlocalized pain, abdominal distention, lack of abdominal guarding, fever, dehydration, diarrhea, and unusual symptoms such as upper gastrointestinal bleeding. In each of these 6 patients the appendix was ruptured. Delays led to complications and deaths. Three patients required perioperative transfusions to treat excessive bleeding and two patients with ruptured appendicitis developed wound abscesses. Two patients died; in one, ruptured appendix was diagnosed only at autopsy. The other patient died of uncontrolled sepsis. Typhlitis occurring during induction chemotherapy may present similarly and is the main differential diagnosis. Typhlitis will usually improve with medical treatment alone. Nausea and vomiting (13/16), right lower quadrant pain (13/16), guarding (14/16), tachycardia (12/16), fever (10/16), and rebound tenderness (10/16) were the most frequent signs and symptoms of appendicitis. Persistent localized abdominal pain and guarding, lack of improvement with medical treatment, clinical deterioration, and the development of a mass were our indications for laparotomy. Despite major improvements in therapy, there is still a 37.5% error rate in our ability to accurately diagnose appendicitis in pediatric cancer patients.

Management of neutropenic colitis

Neutropenic colitis is recognized as a rare complication of chemotherapy in haematological malignancies. By contrast, the complication is less well known in relationship to chemotherapy for solid malignancies. There are very few examples reported and this paper adds three further cases and reviews the literature. We emphasize that although some cases of neutropenic colitis may be managed medically, full thickness involvement of the bowel wall may lead to perforation and require surgery. The pathogenesis of this progression is discussed and it is concluded that clinical awareness is important in the diagnosis. The signs of peritonitis or septicaemia are indications for excisional surgery with the formation of a temporary ileostomy.

Neutropenic enterocolitis. Clinical diagnosis and treatment

Review of the consultation records of the Gastrointestinal Surgical Oncology service at Roswell Park Memorial Institute from 1982 to 1987 revealed 22 patients with a clinical diagnosis of neutropenic enterocolitis. Ninety-one percent of the patients had hematologic malignancies, and 95% were receiving cytotoxic chemotherapy. Sixteen patients were treated nonsurgically; 11 died. Of those 11 cases, autopsies were performed in 9. At autopsy, the clinical diagnosis was confirmed in four cases; four cases were found to have normal intestinal tracts, and one case had a small bowel volvulus. In none of the four cases for which autopsy proved neutropenic enterocolitis was transmural bowel necrosis or perforation found. Laparotomy was performed in six patients; three survived. The clinical diagnosis was verified in four of the six patients. Neutropenic enterocolitis must be considered a diagnosis of exclusion. Care of these patients should be individualized. Nonoperative management with bowel rest, decompression, nutritional support, and broad spectrum antibiotics is recommended initially. Operative intervention is recommended for those with perforation or those whose condition deteriorates clinically during close, frequent observation.

Neutropenic enterocolitis following treatment with cytosine arabinoside-containing regimens for hematological malignancies: a potentiating role for amsacrine

A retrospective clinical study was performed to determine the clinical impact of neutropenic enterocolitis (NE) in adult patients with acute leukemia and non-Hodgkin's lymphoma treated with cytosine arabinoside (Ara-C)-containing regimens. The diagnosis of NE was restricted to conditions with clinical signs of peritonitis, ileus, or intestinal hemorrhage. Forty episodes of NE were noted during 461 Ara-C-containing courses (8.6%) in 36 of 211 patients (17%) over a 6-year period. Clinically, 18 cases of ileus, 16 cases of peritonitis, and 6 cases of intestinal hemorrhage were recognized as the most important presentation of NE. NE started about 2 weeks after the initiation of the chemotherapy and lasted for an average of 1 week. All patients had a profound neutropenia. The incidence of septicemia was higher during courses complicated by NE (p less than 0.001). All cases of NE were treated with conservative measures. The mortality was 22.5% and represented one third of all therapy-related deaths during the pancytopenic period. The incidence of NE was significantly higher in courses consisting of high-dose Ara-C for 6 consecutive days when the drug was combined with amsacrine for 3 consecutive days (p less than 0.0001).

Surgical management of neutropenic enterocolitis

Three cases of histologically confirmed neutropenic enterocolitis, each presenting as an acute abdomen in patients with leukaemia are presented. All three patients presented with fever and abdominal pain within 14 days of completing a course of chemotherapy. Signs of peritonitis localized to the right iliac fossa developed in each patient, in spite of aggressive antibiotic therapy and bowel rest. All three patients were found to have non-viable caecum at laparotomy and were treated by right hemicolectomy. Primary ileocolic anastomosis was performed in one patient, who recovered following a stormy postoperative course owing to sepsis. Two patients underwent formation of an ileostomy with distal mucous fistula and each recovered with minimal postoperative complications; secondary anastomosis was performed electively in both cases. The difficulty in diagnosing neutropenic enterocolitis preoperatively is discussed and the place of non-operative management is reviewed but we recommend surgical intervention as a means of ensuring removal of a localized septic focus until marrow regeneration occurs.

Recurrent typhlitis. A disease resulting from aggressive chemotherapy

Neutropenic typhlitis is a frequently fatal disease most commonly reported in leukemics. The authors have treated eight such patients over the last 18 months. All patients had abdominal pain and sepsis during chemotherapy-induced neutropenia. CT scanning was diagnostic in six patients thought to have typhlitis. Two patients were not diagnosed before exploratory laparotomy. The authors have found nonoperative treatment highly effective in patients who do not manifest signs of peritonitis, perforation, gastrointestinal hemorrhage, or clinical deterioration. Recurrent typhlitis was frequent after conservative therapy (recurrence rate, 67 percent), however. One patient underwent an elective right hemicolectomy after a second episode, and typhlitis did not recur despite neutropenia associated with a subsequent course of chemotherapy. It is concluded that successful treatment of this disease hinges on: 1) early diagnosis provided by a high index of suspicion and the use of CT scanning, 2) nonoperative treatment for uncomplicated cases, and 3) elective right hemicolectomy to prevent recurrence.

Remission induction in children with acute non-lymphocytic leukemia using cytosine arabinoside and doxorubicin or daunorubicin: a report from the Childrens Cancer Study Group

Four hundred ninety evaluable patients were treated on an induction regimen consisting of two to four courses of cytosine arabinoside plus an anthracycline. Overall, 78% of patients went into remission, 10% died during induction, and 12% were induction failures. For the first 152 patients, courses consisted of 7 days continuous infusion with cytosine arabinoside (Ara-C, 100 mg/m2) and 3 days of doxorubicin (30 mg/m2). Because of unacceptable toxicity, particularly for children less than 3 years of age, the anthracycline was changed to daunorubicin, and the doses of both induction drugs for children under 3 was reduced. For children aged 3 years and older the change in anthracycline was associated with a significant increase in induction failures (7% to 16%, P = .04) and a decrease in deaths (15% to 8%, P = .09). For younger children, for whom doses were also changed, the effect was greater; Mortality decreased from 29% to 1% (P less than .0001), and the remission induction rate increased from 66% to 88% (P = .005). The therapy modifications also influenced survival following remission induction: Daunorubicin-treated patients, aged 3 years and over, did significantly better than those given doxorubicin (P = .03), but the opposite was seen in younger children (P = .06). Gastrointestinal and skin toxicities and septicemia were significantly more common when doxorubicin was being used, but the extent of myelosuppression was similar for the two anthracyclines.