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Carachi R, Grosfeld JL. Surgical Complications of Childhood Tumors. THE SURGERY OF CHILDHOOD TUMORS 2016. [PMCID: PMC7121030 DOI: 10.1007/978-3-662-48590-3_31] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- Robert Carachi
- Surgical Paediatrics, University of Glasgow, Glasgow, United Kingdom
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Abstract
Neutropenic enterocolitis, also known as typhlitis or ileocecal syndrome, is a rare, but important, complication of neutropenia associated with malignancy. It occurs as a result of chemotherapeutic damage to the intestinal mucosa in the context of an absolute neutropenia and can rapidly progress to intestinal perforation, multisystem organ failure, and sepsis. Presenting signs and symptoms may include fever, abdominal pain, nausea, vomiting, and diarrhea. Rapid identification and timely, aggressive medical and/or surgical intervention are the cornerstones of survival for these patients.
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Abstract
Data on the risk factors for typhlitis in children with cancer are limited. The aim of the study was to define the epidemiologic and clinical features of typhlitis and to elucidate predisposing factors for its development. The medical records of pediatric patients with cancer who were diagnosed with typhlitis from 1995 to 2005 were reviewed for clinical, laboratory, and imaging findings. The results were compared with a group of patients with cancer but without typhlitis who were hospitalized during the same period. Of the 843 cancer patients, 42 (5%) had episodes of typhlitis; 32 of them (76%) were being treated for hematologic malignancies. The incidence was highest in patients with Burkitt's lymphoma (15%) and acute myeloblastic leukemia (12%). Work-up included abdominal x-ray in all patients; abdominal ultrasonography and computed tomography were performed in 23% and 11% of patients, respectively. No cases were missed by plain x-ray when compared with computed tomography and ultrasonography. The typhlitis was treated without surgery and survival was 100%. On multivariate analysis, mucositis [odds ratio (OR) = 30.7], stem cell transplantation (OR = 58.9), and receipt of chemotherapy in the previous 2 weeks (OR = 12.9) were significantly associated with the occurrence of typhlitis. We conclude that most children with typhlitis may be treated without surgery in most cases with favorable outcome. A high index of suspicion may be warranted in patients after stem cell transplantation or chemotherapy and patients with mucositis.
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Ullery BW, Pieracci FM, Rodney JRM, Barie PS. Neutropenic enterocolitis. Surg Infect (Larchmt) 2009; 10:307-14. [PMID: 19566419 DOI: 10.1089/sur.2008.061] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Neutropenic enterocolitis, sometimes called typhilitis, is the most common gastrointestinal infection related to neutropenia, but its rarity, confusing terminology, and protean, non-specific manifestations result in variable approaches to diagnosis and management. METHODS Review of pertinent English-language literature. RESULTS The true incidence of neutropenic enterocolitis is unknown, but may be 5% or more among adult patients receiving chemotherapy for solid malignant tumors. The incidence is reported to be slightly lower in children. Estimates are made complex by recent recognition that neutropenia of any cause may be associated with enterocolitis; reports of non-chemotherapy drug-associated cases are increasing. Mortality rates are reported currently to be between 30% to 50%. The exact pathogenesis is also unknown, and may contribute to the varied nomenclature in use. Gut mucosal ulcerations may result from direct drug-related cytotoxicity, or from neutropenia itself. Microbial invasion of the bowel wall proceeds unimpeded. Pathological changes include inflammation and edema, presumably followed by ulceration, transmural necrosis, and perforation. The classic clinical presentation consists of fever, abdominal pain, and neutropenia, but diagnosis is often hindered by subtle or non-specific clinical findings, making computed tomography the linchpin of diagnosis. The wide spectrum of clinical presentation requires an individualized approach to therapy. Medical management, including administration of granulocyte colony-stimulating factor, may be appropriate for patients who do not have gastrointestinal bleeding, peritonitis, or intestinal perforation. Surgical management is generally reserved for patients who fall into any of the exceptional categories, and consists usually of bowel resection and stoma creation. CONCLUSIONS Neutropenic enterocolitis is a heterogeneous diseazse state with the capacity to affect many areas of the gastrointestinal tract, and disease severity that ranges from mild to fatal. A high index of suspicion is needed for all patients who present with fever and abdominal pain in the setting of neutropenia. Early detection allows a majority of cases to resolve with nonoperative management and supportive care, but surgical intervention is mandatory for peritonitis, bowel perforation, or gastyrointestinal hemorrhage that persists despite correction of coagulopathy.
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Affiliation(s)
- Brant W Ullery
- Department of Surgery, Weill Cornell Medical College, New York, New York 10021, USA
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Abstract
Neutropenic enterocolitis, also known as typhlitis or ileocecal syndrome, is a rare but important complication of neutropenia associated with malignancy. It occurs as a result of chemotherapeutic damage to the intestinal mucosa in the context of an absolute neutropenia, and can rapidly progress to intestinal perforation, multisystem organ failure, and sepsis. Presenting signs and symptoms may include fever, abdominal pain, nausea, vomiting, and diarrhea. Rapid identification by emergency physicians and timely, aggressive medical and/or surgical intervention are the cornerstones of survival for these patients.
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Affiliation(s)
- Robert L Cloutier
- Department of Emergency Medicine, Doernbecher Children's Hospital, Oregon Health & Science University, Portland, OR 97239, USA.
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Abstract
The most common complaints among patients with cancer who present to the emergency department are related to the gastrointestinal system, and 40% of these patients complain of abdominal pain. These presentations can stem from the underlying malignancy itself, treatment directed toward the disease, or the full range of pathologies present in a healthy population. Immunosuppression may blunt many of the findings one expects in a healthy population of patients, thus rendering the clinical exam less reliable in many patients with cancer. Moreover, the degree of immunosuppression shapes both the types of pathologies the clinician should consider and the rate at which the disease may progress. Understanding the limitations of physical examination, pathophysiology of disease, and the methods by which these diagnoses are established is of critical importance in this population. This article focuses specifically on patients with cancer who present with an acute abdomen, and it discusses how a concurrent malignancy can shape the differential diagnosis in these cases.
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Affiliation(s)
- Jonathan S Ilgen
- Department of Emergency Medicine, Oregon Health & Science University, CDW-EM, Portland, OR 97239, USA.
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Surgical Complications of Childhood Tumors. THE SURGERY OF CHILDHOOD TUMORS 2008. [PMCID: PMC7122594 DOI: 10.1007/978-3-540-29734-5_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Most childhood tumors will first present to a physician; some tumors will present in an atypical manner and may mimic a surgical condition. The diagnosis may be missed if the surgeon is not aware of the possibility of cancer. A very great number of rare presentations of childhood cancer have been described in the literature. It is important that the surgeon who is not experienced in the management of childhood cancer is aware that an apparently benign condition could be a manifestation of an underlying malignancy [71, 83] (Table 22.1).
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Abstract
PURPOSE OF REVIEW This review will cover the recent literature pertaining to the pathogenesis, diagnosis, and management of patients with neutropenic enterocolitis. RECENT FINDINGS Neutropenic enterocolitis, also referred to as typhlitis, is a life-threatening gastrointestinal complication of chemotherapy, most often associated with leukemia or lymphoma. Recently, a larger number of reports have been published of individuals presenting with this syndrome after being treated with newer chemotherapeutic agents for solid tumors such as non-small cell lung, ovarian, and peritoneal cancer, as well as following autologous stem cell transplantation. Recent studies have also better characterized computed tomographic and ultrasonographic features of this entity that can help differentiate neutropenic enterocolitis from other gastrointestinal complications. A newly published systematic analysis of the literature, which included 145 articles, defines appropriate diagnostic criteria and treatment recommendations. SUMMARY Neutropenic enterocolitis is a serious, potentially lethal complication of anticancer therapy. The studies discussed in this review will help the practitioner make an appropriate, early diagnosis and implement a therapeutic program that would improve the outcome of these patients.
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MESH Headings
- Antineoplastic Combined Chemotherapy Protocols/adverse effects
- Antineoplastic Combined Chemotherapy Protocols/therapeutic use
- Combined Modality Therapy
- Enterocolitis, Neutropenic/chemically induced
- Enterocolitis, Neutropenic/diagnosis
- Enterocolitis, Neutropenic/epidemiology
- Enterocolitis, Neutropenic/therapy
- Female
- Humans
- Incidence
- Intestinal Mucosa/pathology
- Leukemia, Myeloid, Acute/diagnosis
- Leukemia, Myeloid, Acute/drug therapy
- Lymphoma, Non-Hodgkin/diagnosis
- Lymphoma, Non-Hodgkin/drug therapy
- Male
- Prognosis
- Risk Assessment
- Severity of Illness Index
- Survival Rate
- Tomography, X-Ray Computed
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Affiliation(s)
- Marta L Davila
- Department of Gastrointestinal Medicine and Nutrition, University of Texas MD Anderson Cancer Center, Houston, Texas 77030-4009, USA.
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McCarville MB, Adelman CS, Li C, Xiong X, Furman WL, Razzouk BI, Pui CH, Sandlund JT. Typhlitis in childhood cancer. Cancer 2005; 104:380-7. [PMID: 15952190 DOI: 10.1002/cncr.21134] [Citation(s) in RCA: 100] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Typhlitis is increasingly recognized in children undergoing chemotherapy but is poorly characterized. The authors investigated the demographic, clinical, and imaging (ultrasonography and computed tomography [CT] scans) variables related to the diagnosis, risk, and outcome of typhlitis. METHODS The authors reviewed the records of patients who had typhlitis (bowel wall thickness > or = 0.3 cm plus clinical findings) during treatment at St. Jude Children's Research Hospital (Memphis, TN) between 1990 and 2001. They assessed whether duration of typhlitis was related to bowel wall thickness, extent of colonic involvement, ascites, demographics, primary diagnosis, symptoms of typhlitis, or duration of neutropenia. To identify risk factors for typhlitis, the authors compared the demographic data and previous drug therapy of 78 patients who had typhlitis and 1231 identically treated children who did not. RESULTS Of 3171 children, 83 (2.6%) developed typhlitis. Frequent symptoms were abdominal pain (91%), fever (84%), abdominal tenderness (82%), and diarrhea (72%). Twelve percent of the patients were not neutropenic. Duration of typhlitis was associated with bowel wall thickness measured by ultrasonography (n = 68; P = 0.05) but not CT scan (n = 48; P = 0.67) and was associated with duration of neutropenia (P = 0.02), fever (P = 0.01), and abdominal tenderness (P = 0.04). Age >16 years at cancer diagnosis was the only demographic factor associated with typhlitis (P = 0.03). Two patients died of typhlitis. CONCLUSIONS Ultrasonography was a useful imaging modality for children with suspected typhlitis. The classic triad of abdominal pain, fever, and neutropenia may be absent. The severity of typhlitis was related to the duration of neutropenia and the presence of fever or abdominal tenderness.
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Affiliation(s)
- M Beth McCarville
- Division of Diagnostic Imaging, Department of Radiological Sciences, St. Jude Children's Research Hospital, Memphis, Tennessee 38105, USA. beth.mccarville@st jude.org
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Cunningham SC, Fakhry K, Bass BL, Napolitano LM. Neutropenic enterocolitis in adults: case series and review of the literature. Dig Dis Sci 2005; 50:215-20. [PMID: 15745075 DOI: 10.1007/s10620-005-1585-1] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Necrotizing enterocolitis in adults is a rare disease and, in the past, has been associated with nearly uniform mortality. In recent years, necrotizing enterocolitis, now termed neutropenic enterocolitis, in adults has become more prevalent as a complication of aggressive systemic chemotherapy. In this report, we discuss two cases of neutropenic enterocolitis secondary to the administration of systemic chemotherapy in adult cancer patients: one with lung carcinoma, the other with leukemia. Both patients were successfully treated with early surgical intervention for resection of all necrotizing enteric lesions, and subsequent aggressive critical care support. Our experience suggests that early surgical intervention in adult patients with intestinal necrosis due to chemotherapy is essential to avoid mortality from this condition. Given the widespread, aggressive use of systemic chemotherapy in the neoadjuvant setting, patients at risk for this potentially lethal complication of neutropenic enterocolitis are increasingly common.
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Affiliation(s)
- Steven C Cunningham
- Department of Surgery, Baltimore VA Medical Center, University of Maryland School of Medicine, Baltimore, Maryland, USA
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Wilson DB, Rao A, Hulbert M, Mychaliska KP, Luchtman-Jones L, Hill DA, Foglia RP. Neutropenic enterocolitis as a presenting complication of acute lymphoblastic leukemia: an unusual case marked by delayed perforation of the descending colon. J Pediatr Surg 2004; 39:e18-20. [PMID: 15213940 DOI: 10.1016/j.jpedsurg.2004.03.083] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Neutropenic enterocolitis (NE) is a life-threatening complication most commonly seen in patients receiving intensive chemotherapy for acute leukemia. The condition usually affects the terminal ileum, cecum, or ascending colon. In rare instances, NE may occur before the initiation of chemotherapy or involve more distal bowel. The authors report the case of a 2-year-old girl who had NE affecting the descending colon as a presenting complication of acute lymphoblastic leukemia. Despite aggressive medical interventions, including granulocyte infusions, she had a delayed bowel perforation that was managed successfully with surgery. This case highlights the challenges of treating patients who have NE as an initial manifestation of acute leukemia.
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Affiliation(s)
- David B Wilson
- Department of Pediatrics, Washington University School of Medicine, St Louis, MO 63110, USA
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Köhler H, Nurko S, Glickman J, Furuta GT. Acute myeloid leukemia presenting as non-neutropenic colitis in an infant. J Pediatr Gastroenterol Nutr 2003; 37:631-3. [PMID: 14581811 DOI: 10.1097/00005176-200311000-00025] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Affiliation(s)
- Henrik Köhler
- Divison of Gastroenterology and Nutrition, Children's Hospital Boston, Harvard Medical School, Boston, Massachusetts 02115, USA
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Schlatter M, Snyder K, Freyer D. Successful nonoperative management of typhlitis in pediatric oncology patients. J Pediatr Surg 2002; 37:1151-5. [PMID: 12149691 DOI: 10.1053/jpsu.2002.34461] [Citation(s) in RCA: 50] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND/PURPOSE The optimal management for typhlitis in pediatric oncology patients has not always been clear from the medical literature. Trends have varied between operative and nonoperative approaches. The aim of this study was to review the successful nonoperative management of these patients at our institution over the last decade to further clarify management guidelines for this difficult problem. METHODS Medical records of pediatric hematology and oncology patients up to 21 years of age with typhlitis diagnosed at the DeVos Children's Hospital from 1990 to 2000 were reviewed. RESULTS Twelve patients were included. Ten patients (83%) with computed tomography (CT) scans suggestive of the diagnosis were treated successfully nonoperatively. Management usually included bowel rest, antibiotics, and supplemental parenteral nutrition. Two patients (17%) in whom CT scans were not obtained underwent surgery for presumed appendicitis and pneumoperitoneum, respectively. Typhlitis was found incidentally. In the latter patient, the pneumoperitoneum resulted from a perforated jejunum caused by graft-versus-host disease. This patient died of septic complications and was the only mortality in the series (8%). CONCLUSIONS Pediatric cancer patients with typhlitis can be treated carefully nonoperatively with bowel rest, antibiotics, and supplemental nutrition. Usual indications for surgery (ie, perforation, clinical deterioration) still should be used. The early use of CT scanning helps to facilitate the diagnosis and may provide the ability to differentiate typhlitis from other abdominal diseases for which surgery would be indicated.
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Affiliation(s)
- Marc Schlatter
- Department of Pediatric Surgery, DeVos Children's Hospital, Grand Rapids, MI, USA
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Abdul Wahid FBS, Keng CS, Ali RBA. Acute leukaemia masquerading as acute abdomen. HOSPITAL MEDICINE (LONDON, ENGLAND : 1998) 2002; 63:372-3. [PMID: 12096671 DOI: 10.12968/hosp.2002.63.6.2011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
This article reports three patients with acute leukaemia who presented with acute abdomen as the first manifestation of the disease. Leukaemic infiltrates of the bowel and appendix may have caused the abdominal symptoms in these patients. Acute leukaemia should be included in the differential diagnosis of severe abdominal pain associated with an abnormal blood count. This report highlights the importance of early diagnosis of acute leukaemia as initiation of cytotoxic chemotherapy results in prompt resolution of the abdominal catastrophe and obviates the need for surgery.
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Affiliation(s)
- Fadilah binti S Abdul Wahid
- Division of Haematology and Stem Cell Transplantation, MAKNA Hospital Universiti Kebangsaan Malaysia Cancer Institute, Kuala Lumpur, Malaysia.
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Furman WL, Stewart CF, Kirstein M, Kepner JL, Bernstein ML, Kung F, Vietti TJ, Steuber CP, Becton DL, Baruchel S, Pratt C. Protracted intermittent schedule of topotecan in children with refractory acute leukemia: a pediatric oncology group study. J Clin Oncol 2002; 20:1617-24. [PMID: 11896112 DOI: 10.1200/jco.2002.20.6.1617] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE To determine dose-limiting toxicity (DLT) and maximum-tolerated dose (MTD) of a protracted, intermittent schedule of daily 30-minute infusions of topotecan (TPT) for up to 12 consecutive days, every 3 weeks, in children with refractory leukemia. PATIENTS AND METHODS Forty-nine children were enrolled onto this phase I trial (24 with acute nonlymphoblastic leukemia [ANLL] and 25 with acute lymphoblastic leukemia [ALL]). TPT dosage was escalated from 2.0 to 5.2 mg/m(2)/d for 5 days and 2.4 mg/m(2)/d from 7 days to the same dose for 9 and 12 days in cohorts of three to six patients when no DLT was identified. TPT pharmacokinetics were studied in 33 children once or twice (first and last doses in patients who received TPT for > 7 days). RESULTS Seventy assessable courses of TPT were administered to 49 children who had refractory leukemia. DLTs were typhlitis, diarrhea, and mucositis, and the MTD was 2.4 mg/m(2)/d for 9 days in this group of heavily pretreated children. In 33 patients, the median TPT lactone clearance after the first dose was 19.2 L/h/m(2) (range, 9.4 to 45.9 L/h/m(2)) and did not change during the course. There were significant responses (one complete response [CR] and four partial responses [PR] in patients with ANLL and one CR and two PRs in patients with ALL), and all but one were at dosages of TPT given for at least 9 days. CONCLUSION The MTD was 2.4 mg/m(2)/d for 9 days. Further testing is warranted of TPT's schedule dependence in children with leukemia.
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Affiliation(s)
- Wayne L Furman
- Department of Hematology-Oncology, St Jude Children's Research Hospital, Memphis, TN, USA.
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Abstract
Neutropenic enterocolitis is a necrotizing inflammatory process with intramural infection that occurs predominantly in neutropenic patients. This syndrome is most frequently observed after chemotherapy for hematologic and solid tissue malignancies, but it can also be observed in a number of other clinical settings as well. Neutropenic enterocolitis can be a rare presenting complication of acute leukemia. We report a case of acute lymphoblastic leukemia that presented with abdominal pain due to neutropenic enterocolitis. The diagnostic and treatment challenges associated with this manner of presentation are discussed.
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Affiliation(s)
- M M Quigley
- Laboratory Department, Naval Medical Center, San Diego, California 92134-1005, USA.
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Kaste SC. Infection imaging of children and adolescents undergoing cancer therapy: A review of modalities and an organ system approach. ACTA ACUST UNITED AC 2000. [DOI: 10.1053/pi.2000.4662] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Manglani MV, Rosenthal J, Rosenthal NF, Kidd P, Ettinger LJ. Intussusception in an infant with acute lymphoblastic leukemia: a case report and review of the literature. J Pediatr Hematol Oncol 1998; 20:467-8. [PMID: 9787321 DOI: 10.1097/00043426-199809000-00011] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
PURPOSE An ileocecal intussusception developed in a 7-month-old infant with acute lymphoblastic leukemia (ALL) during induction therapy. Gastrointestinal complications, especially intussusception, are rare in children with ALL. PATIENT AND METHODS The history of a 7-month-old white boy with ALL in whom an ileocecal intussusception developed 1 week into induction chemotherapy was reviewed. In addition, a literature search was performed to determine the prevalence of this complication in children with acute leukemia. RESULTS On day 4 of induction chemotherapy for B-lineage ALL, the infant developed abdominal distension with hypoactive bowel sounds. After a barium enema and abdominal computed tomography scan, the symptoms were determined to be caused by an ileocecal intussusception. Chemotherapy was resumed 1 week after immediate surgical intervention (reduction of intussusception and resection of the "leading edge") with an uneventful post-operative recovery. Histopathologic examination of the resected edge revealed an intact mucosa with areas of necrosis in the submucosa. This was associated with a dense lymphoid infiltrate composed of mature lymphocytes and leukemic cells, edema, and focal necrosis. Despite a 1-week delay in chemotherapy, a complete remission was documented at day 32. DISCUSSION The prevalence of intussusception in children with ALL and its possible etiology are discussed. The pathologic changes, clinical manifestations, and treatment outcome are briefly mentioned.
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Affiliation(s)
- M V Manglani
- Division of Pediatric Hematology-Oncology, University of Medicine and Dentistry of New Jersey-Robert Wood Johnson Medical School, USA
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