Low rate of infectious enterocolitis in allogeneic stem cell transplant recipients with acute diarrhea: A prospective study by the GETH-TC

Acute diarrhea is a common and debilitating complication in recipients of an allogeneic hematopoietic stem cell transplantation (HCT). In this prospective, observational, and multi-center study we examined all episodes occurring in the first 6 months of 142 consecutive adult patients who underwent a reduced-intensity conditioning (RIC) HCT in 10 Spanish tertiary University Hospitals. Fifty-four patients (38%) developed a total of 75 acute diarrhea episodes. The median time from HCT to the first episode was 38 days (4-157). The main cause of enterocolitis was lower GI-aGVHD (38%), followed by infections (21%) and drug-related toxicity (8%). Causative infectious causes were identified in only 16/75 episodes (21%). C. difficile-related infection (CDI) was the most common infectious agent with an incidence and recurrence of 13% and 2%, respectively. With a median follow-up for survivors of 32 months, the NRM and the overall survival (OS) at 1 year, were 20% (95% C.I.: 14-28%) and 69% (95% C.I.: 61-77%), respectively. Development of enterocolitis was not associated with higher NRM (p = 0.37) or worse OS (p = 0.9). This real-life study confirms that the diagnosis and management of acute diarrhea in the early stages after HCT is challenging. Nosocomial infections, seem to be relatively uncommon, probably due to more rational use of antibiotics.

Early-life gut dysbiosis linked to juvenile mortality in ostriches

BACKGROUND

Imbalances in the gut microbial community (dysbiosis) of vertebrates have been associated with several gastrointestinal and autoimmune diseases. However, it is unclear which taxa are associated with gut dysbiosis, and if particular gut regions or specific time periods during ontogeny are more susceptible. We also know very little of this process in non-model organisms, despite an increasing realization of the general importance of gut microbiota for health.

METHODS

Here, we examine the changes that occur in the microbiome during dysbiosis in different parts of the gastrointestinal tract in a long-lived bird with high juvenile mortality, the ostrich (Struthio camelus). We evaluated the 16S rRNA gene composition of the ileum, cecum, and colon of 68 individuals that died of suspected enterocolitis during the first 3 months of life (diseased individuals), and of 50 healthy individuals that were euthanized as age-matched controls. We combined these data with longitudinal environmental and fecal sampling to identify potential sources of pathogenic bacteria and to unravel at which stage of development dysbiosis-associated bacteria emerge.

RESULTS

Diseased individuals had drastically lower microbial alpha diversity and differed substantially in their microbial beta diversity from control individuals in all three regions of the gastrointestinal tract. The clear relationship between low diversity and disease was consistent across all ages in the ileum, but decreased with age in the cecum and colon. Several taxa were associated with mortality (Enterobacteriaceae, Peptostreptococcaceae, Porphyromonadaceae, Clostridium), while others were associated with health (Lachnospiraceae, Ruminococcaceae, Erysipelotrichaceae, Turicibacter, Roseburia). Environmental samples showed no evidence of dysbiosis-associated bacteria being present in either the food, water, or soil substrate. Instead, the repeated fecal sampling showed that pathobionts were already present shortly after hatching and proliferated in individuals with low microbial diversity, resulting in high mortality several weeks later.

CONCLUSIONS

Identifying the origins of pathobionts in neonates and the factors that subsequently influence the establishment of diverse gut microbiota may be key to understanding dysbiosis and host development. Video Abstract.

Clinical experience in 89 consecutive cases of chronic radiation enterocolitis

BACKGROUND

Pelvic irradiation has been a popular therapy modality for cervical cancer for many years, and its usage in rectal cancer and prostate cancer cases is on the rise. However, it is associated with significant side effects. In this study, we compared the different characteristics of surgical and nonsurgical patients who were treated for radiation enterocolitis, the treatment results, posttreatment quality of life (QOL), nutrition status, and predisposing factors for surgery.

METHODS

From 1985 to 2009, the records of a total of 89 patients with chronic radiation enterocolitis in our hospital were retrospectively reviewed for demographic data, operative data and long-term treatment results. Posttreatment QOL and nutrition status were also recorded. Univariate and multivariate analyses were performed to identify the independent predicting factors associated with surgical intervention. Characteristics of surgical and nonsurgical patients were compared.

RESULTS

Radiotherapy before 1995, concomitant radiation uropathy and smoking were independent predictive factors for surgery. Surgical and nonsurgical cases had similar Kaplan-Meier curves. Although the recurrence rate of radiation enterocolitis was much higher for the surgical group (p = 0.031), both groups had similar QOL score (median: 8 vs.7; p = 0.709), serum albumin level (3.29 g/dL vs. 3.16 g/dL; p = 0.095), and body mass index (20.19 vs. 19.86; p = 0.603).

CONCLUSIONS

We confirmed that as compared with recently developed innovative techniques, early primitive radiotherapy techniques were associated with more severe radiotherapy complications that required surgery. Smoking may enhance patients' vulnerability to severe radiation injury. Surgery for radiation-induced intestinal obstruction, intestinal fistula and perforation is warranted because QOL, serum albumin level and body mass index were similar between the surgical and nonsurgical groups.

Effects of caprylic acid and triacylglycerols of both caprylic and capric acid in rabbits experimentally infected with enteropathogenic Escherichia coli O103

Eighty-eight rabbits weaned at the age of 35 days were divided into four groups. Rabbits of the first two groups were fed a granulated feed, free of antimicrobials. Rabbits of the 3rd and the 4th groups were fed the same diet, supplemented with caprylic acid at 5 g/kg, and with triacylglycerols (TAG) of caprylic and capric acid at 10 g/kg, respectively. Rabbits of the 2nd, 3rd and 4th groups were challenged orally with 10(9) cells of Escherichia coli of the O103 serogroup. Numbers of coliform bacteria in faeces of non-infected rabbits averaged 4.66 log(10)cfu/g. Six days after inoculation, caprylic acid and TAG of caprylic and capric acid decreased faecal output of coliforms from 10.18+/-0.62 to 7.79+/-0.48 log(10)cfu/g and 8.04+/-0.50 log(10)cfu/g, respectively. In the 2nd, 3rd and 4th groups 15, 11 and 9 infected rabbits died, respectively. However, the differences in mortality rate were not statistically significant. Surviving rabbits were slaughtered at 53 days of age. In caecal contents of infected rabbits, numbers of coliform bacteria were significantly reduced from 8.71 log(10)cfu/g to 5.55-5.83 log(10)cfu/g in treated groups. It can be concluded that both antimicrobial lipids are active against coliform bacteria, and may improve the resistance of weaned rabbits to enterocolitis.

MyD88-dependent pathways mediate resistance to Cryptosporidium parvum infection in mice

Cryptosporidium spp. cause diarrheal disease worldwide. Innate immune responses mediating resistance to this parasite are not completely understood. To determine whether MyD88-dependent pathways play a role in resistance to Cryptosporidium parvum, we compared the course of infection in MyD88(-/-) mice to that in their wild-type (WT) littermate controls. Three- to 4-week-old mice were infected with C. parvum, and infection was monitored by quantifying fecal oocyst shedding. Twelve days postinfection, the histology of the intestines was examined to quantify intestinal parasite burden and to determine if there were any pathological changes. Fecal oocyst shedding and intestinal parasite burden were significantly greater in MyD88(-/-) mice than in littermate controls. Nonetheless, both WT and MyD88(-/-) mice cleared the infection within 3 weeks. These results indicate that MyD88-dependent pathways are involved in mediating initial resistance to C. parvum. Since gamma interferon (IFN-gamma) is known to mediate resistance to C. parvum, we also studied infection in MyD88(-/-) mice and WT controls in which this cytokine was temporarily neutralized. Fecal oocyst shedding, as well as intestinal parasite burden, intestinal inflammation, and mortality, was significantly greater in MyD88(-/-) mice in which IFN-gamma was neutralized than in IFN-gamma-neutralized WT mice or in MyD88(-/-) mice in which this cytokine was active. These results suggest that MyD88 and IFN-gamma had an additive effect in conferring protection from C. parvum infection. While this study confirms the importance of IFN-gamma in conferring resistance to infection with C. parvum, it suggests that MyD88-mediated pathways also play a role in innate immunity to this parasite.

Intestinal Ischemia

Context.—As rejection in renal transplantation has become better controlled, gastrointestinal complications have become increasingly important. Ischemic colitis and colonic perforation are the most common of these lesions, contributing to morbidity and mortality in the early postoperative period.

Objective.—We undertook this study to identify factors contributing to the risk of intestinal ischemia in patients undergoing renal transplantation and to define circumstances that may affect that risk.

Methods.—We studied 356 patients undergoing renal transplantation during a 40-month period. We reviewed medical records, surgical pathology reports, autopsy reports, and pathology slides.

Results.—Eleven (3.1%) of the patients developed ischemia of the small or large bowel or both within 20 days after transplantation, and 6 (54.5%) died as a result. Ten of these patients had received cadaveric kidneys and were older than 40 years. There was no sex predilection. The most common segment involved was the terminal ileum and ascending colon. We discuss possible reasons underlying these observations in this article.

Conclusion.—The mechanism behind posttransplantation intestinal ischemia is multifactorial, but regardless of etiology, it is important to emphasize the risk of intestinal ischemia in patients who develop abdominal symptoms during the early posttransplantation period, particularly in patients older than 40 years who have received cadaveric kidneys.

Neutropenic enterocolitis

Neutropenic enterocolitis is an acute syndrome characterized by cecal and ascending colon inflammation that may progress to necrosis and perforation. It is most often associated with leukemia but has also been described in patients with solid tumors, multiple myeloma, aplastic anemia, AIDS, and cyclic neutropenia. Medical management usually suffices, but surgical intervention may be required.

A mouse model for postoperative fatal enteritis due to Staphylococcus infection

BACKGROUND

Postoperative infection of intestine with methicillin-resistant Staphylococcus aureus (MRSA) is fatal in some cases. The object of this study was to establish a mouse model for the infection, providing a useful tool for investigating mechanisms in the progression of infection.

METHODS

Mice were pretreated with cyclophosphamide, injected orally or directly into jejunum with MRSA prepared from a postoperative patient, and then given 5 daily doses of antibiotics. Forty-eight hours after the injection, bacterial translocation and serum endotoxin levels were examined. Macrophage depletion was carried out by the administration of liposome-encapsulated dichloromethylene diphosphate (Cl(2)MDP), 4 days before MRSA injection.

RESULTS

Injection into the jejunum but not oral administration of MRSA induced enteritis with diarrhea and resulted in death in most cyclophosphamide-treated mice. Translocation of MRSA in mesenteric lymph nodes and liver was observed, concomitantly with E. coli infection. Endotoxin-resistant C3H/HeJ mice infected with MRSA survived longer than endotoxin-sensitive C3H/He mice, but also died within a week after MRSA injection. Selective depletion of macrophages induced infection in mice that were not pretreated with cyclophosphamide.

CONCLUSION

We established a mouse model for the fatal MRSA infection which induced enteritis with diarrhea, that will be a useful tool for investigating the mechanisms for sometimes fatal MRSA infection of the intestine in postoperative patients. The presence of E. coli or endotoxin seemed to play a major role in the mortality of mice in the early days of MRSA-induced enteritis, but other factors, probably from MRSA, in the later days. Phagocytes were quite important for protection against the MRSA infection.

Neutropenic enterocolitis in patients with acute leukemia: prognostic significance of bowel wall thickening detected by ultrasonography

PURPOSE

Neutropenic enterocolitis (NE) is a severe complication of intensive chemotherapy and is barely identifiable by clinical signs alone. Ultrasonography (US) supports the diagnosis of NE by showing pathologic thickening of the bowel wall. The aim of this study was to evaluate the prognostic value of the degree of mural thickening evaluated by US in patients with clinically suspected NE.

PATIENTS AND METHODS

Neutropenic patients with fever, diarrhea, and abdominal pain after intensive chemotherapy for hematologic malignancies were studied with abdominal US. We evaluated the degree of bowel wall thickening detected by US and its correlation with the duration of the clinical syndrome as well as NE-related mortality.

RESULTS

Eighty-eight (6%) of 1,450 consecutive patients treated for leukemia had clinical signs of NE. In 44 (50%) of 88 patients, US revealed pathologic wall thickening (mean +/- SD, 10.2 +/- 2.9 mm; range, 6 to 18). The mean duration of symptoms was significantly longer in this group (7.9 days) than among patients without mural thickening (3.8 days, P <.0001), and the NE-related mortality rate was higher (29.5% v 0%, P <.001). Patients with bowel wall thickness of more than 10 mm had a significantly higher mortality rate (60%) than did those with bowel wall thickness < or = 10 mm (4.2%, P <.001).

CONCLUSION

Symptomatic patients with sonographically detected bowel wall thickening have a poor prognosis compared with patients without this finding. In addition, mural thickness of more than 10 mm is associated with poorer outcome among patients with NE.

[Clinical profile of cytomegalovirus (CMV) enterocolitis in acquired immunodeficiency syndrome]

OBJECTIVE

To determine the clinical profile of CMV colitis in AIDS patients, comparing clinical, endoscopic parameters and survival time between 2 groups of AIDS patients having chronic diarrhea. Group A being CMV colitis and group B without CMV colitis.

METHODS

48 patients with diarrhea that lasted more than 30 days, being 27 in Group A and 21 in Group B, were studied. Age, risk factors, interval time between the diagnosis of HIV infection and the beginning of diarrhea, hematochesia, the endoscopic findings and life table in both groups, were analysed. All of them were diagnosed by stool culture and stools for ovum and parasites, along colonoscopy with biopsies. The unpaired t test was used to assess statistical significance of differences observed in the means of continuous and the chi-square with Yates correction for non-parametric variables. The survival curves were assessed by the Kaplan-Meier and the Mantel-Haenszel's tests. A P value of less than 0,05 was considered to indicate statistical significance.

RESULTS

The mucosal lesions associated with the CMV infection are typically ulcerative on a background of hemorrhagic erythema 14 (51,8%) p < 0,01. The life table analysis disclosed shorter survival time in the CMV colitis group 0,005> P>0,001. The others studied data did not achieve statistical significance.

CONCLUSIONS

AIDS patients with CMV colitis have a poorer long-term survival. Among the colonoscopic findings, ulcerations with hemorrhagic background were the most common lesions.

Indications for laparotomy in infection with verotoxigenic Escherichia coli

Verotoxigenic types of Escherichia coli have emerged as serious and important human pathogens. The clinical disease most frequently manifests as a painful form of bloody diarrhea, which can progress to life-threatening systemic microangiopathic hemolytic anemia, known as the hemolytic-uremic syndrome (HUS). Three children with hemorrhagic enteritis due to verotoxigenic E. coli are presented to illustrate the unique diagnostic, therapeutic, and operative management dilemmas associated with this disease. When contemplating surgery, one should seek to determine the anatomic and transmural extent of the disease.

Expression of the neutrophil chemokine KC in the colon of mice with enterocolitis and by intestinal epithelial cell lines: effects of flora and proinflammatory cytokines

IL-10 plays an important role in preventing excessive inflammation to the normal flora in the intestinal lumen. The purpose of this study was to compare the effect of normal flora on inflammation in mice in which the IL-10 gene was disrupted. IL-10 knock-out mice housed in germfree conditions remained healthy while those housed in conventional conditions developed colitis after weaning, suggesting that IL-10 inhibits the adverse responses to luminal Ag. Crypt abscesses were present in virtually all of the diseased animals as evidenced by flattening of the epithelial cells and a large number of neutrophils in the lumen of the crypt. Since KC is a chemokine that is capable of recruiting neutrophils in mice, mRNA and protein for KC was measured. Increased levels of both KC mRNA and protein were detected in the colon of diseased mice. To determine whether the epithelial cells were capable of synthesizing KC and contributing to neutrophil accumulation in the crypts, a murine intestinal epithelial cell line (Mode-K) was shown to express mRNA and protein for KC. Two cytokines induced in association with colitis in these mice, TNF-alpha and IFN-gamma, increased the expression of KC mRNA and protein in murine epithelial cells. However, IL-10 was incapable of decreasing the induction of KC, even though the cells expressed the IL-10 receptor. These results suggest that the neutrophil chemokine KC is produced by gastrointestinal epithelial cells in response to inflammatory mediators that are expressed following exposure to normal flora in animals lacking IL-10.

Cytomegaloviral enterocolitis: clinical associations and outcome

PURPOSE

Cytomegaloviral enterocolitis is an uncommon disorder that can complicate inflammatory bowel disease. It is more common in patients with acquired immunodeficiency syndrome and can occur in patients on immunosuppressive therapy for autoimmune or inflammatory diseases and in allograft recipients. Mortality rates of up to 71 percent have been reported for cytomegaloviral enterocolitis. The aims of this study were 1) to identify the presentation, underlying medical conditions, treatment, and outcome of patients with cytomegaloviral enterocolitis and 2) to determine the prevalence of this infection in patients undergoing intestinal resection for inflammatory bowel disease.

METHODS

A retrospective chart review of patients with pathologic evidence of cytomegaloviral enterocolitis from 1985 through 1996 was performed. To determine the prevalence of this condition, the hospital discharge database was searched for the diagnoses of ulcerative colitis and Crohn's disease in patients who underwent bowel resection.

RESULTS

93 patients (mean age, 44 years; 66 percent males) had cytomegaloviral infection in the small intestine (n = 6), large intestine (n = 86), or appendix (n = 1). Patients with acquired immunodeficiency syndrome (n = 42), with ulcerative colitis (n = 11), with Crohn's disease (n = 11), receiving organ transplant (n = 12), receiving bone marrow transplant (n = 8), and in other immunosuppressed states (n = 11) comprised this study. Seventeen patients (18 percent) underwent intestinal resection, and the remaining 76 patients were treated medically. Abdominal pain (77 vs. 37 percent; P < 0.01) and gastrointestinal bleeding (65 vs. 34 percent; P < 0.05) were more common presenting symptoms in patients who required resection than patients in the medically managed group. Mortality was 17.6 percent in the surgically managed group and 14.5 percent in the patients who were managed medically. The median duration of ulcerative colitis in patients with coexisting cytomegaloviral infection was 12 months. The prevalence of cytomegaloviral enterocolitis was 4.6 percent in patients with ulcerative colitis and 0.8 percent in patients with Crohn's disease.

CONCLUSIONS

These data suggest that cytomegaloviral infection more frequently complicates ulcerative colitis than Crohn's disease. Furthermore, a short and fulminant course of ulcerative colitis may indicate coexisting cytomegaloviral infection. The overall low mortality in this retrospective study suggests that aggressive medical and surgical treatment improves survival in patients with cytomegaloviral enterocolitis.

Radiation enterocolitis: overview of the past 15 years

From April 1980 to April 1995 a total of 54 patients (53 women, 1 man) were hospitalized in our department for the surgical treatment of radiation enterocolitis. Two surgical protocols were applied for these patients: intestinal decompression procedures alone (intestinal bypass, colostomy, or both; n = 18) or an intestinal resection in addition to decompression (n = 36). The clinical factors contributing to survival after irradiation were retrospectively reviewed by a multiple variate proportional hazards model. As a result, patients treated with decompression procedures alone had an 11 times higher risk for death than those treated with the addition of intestinal resection. In the former group, 5 of 18 patients died of bleeding from the remaining intestine after operation. We concluded that surgical resection of the diseased intestine is a useful procedure for treating radiation enterocolitis to reduce intestinal bleeding from the irradiated intestine.

Clinical risk factors of Hirschsprung-associated enterocolitis. I: Preoperative enterocolitis

Enterocolitis is still the main source of mortality and morbidity in Hirschsprung's disease (HD). Between 1976 and 1993, 79 (26%) of 302 Hirschsprung patients proved to have Hirschsprung-associated enterocolitis (HAEC). Mortality was 7.6 percent (6 patients). HAEC patients, those who died of HAEC and those without HAEC were analyzed for differences in 34 parameters. The length of the aganglionic segment was found not to be a risk factor for HAEC, but early diagnosis and prompt treatment were found to decrease the occurrence of preoperative HAEC. Although we defined HAEC as foul-smelling, explosive diarrhea, some other symptoms and signs, such as abdominal distention on physical examination, vomiting, dehydration, and a history of nonspecific diarrhea were encountered with significant frequency. None of the patients had Down's syndrome. Sepsis was detected in all of the patients who died of HAEC. The severity of HAEC did not increase with the number of attacks of HAEC, and mortality was greater in the first three attacks. Differences in results between some series seemed to be related to differing definitions of HAEC.

Intestinal perforations in infants with a very low birth weight: a disease of increasing survival?

Seventeen infants with a very low birth weight (VLBW) and spontaneous, non-necrotizing enterocolitis (NEC), intestinal perforations are presented; 14 of them were seen in the past 3 years. A comparison with 16 surgically treated NEC infants (< 1,000 g) is provided. At our institution, the yearly survival of VLBW infants increased from 54% to 90% over the past 6 years. All 17 non-NEC patients were operated on, and 15 (88.2%) survived. Ileal perforations were observed frequently. Initial enterostomies were followed by reanastomosis at an average age of 3 months. A 22.6-month follow-up was attained for all survivors. Non-NEC intestinal perforations in tiny neonates are increasing and constitute a challenging but treatable group. The improving survival rate of VLBW infants will probably be accompanied by a variety of complications.

Interleukin-10-deficient mice develop chronic enterocolitis

Interleukin-10 (IL-10) affects the growth and differentiation of many hemopoietic cells in vitro; in particular, it is a potent suppressor of macrophage and T cell functions. In IL-10-deficient mice, generated by gene targeting, lymphocyte development and antibody responses are normal, but most animals are growth retarded and anemic and suffer from chronic enterocolitis. Alterations in intestine include extensive mucosal hyperplasia, inflammatory reactions, and aberrant expression of major histocompatibility complex class II molecules on epithelia. In contrast, mutants kept under specific pathogen-free conditions develop only a local inflammation limited to the proximal colon. These results indicate that the bowel inflammation in the mutants originates from uncontrolled immune responses stimulated by enteric antigens and that IL-10 is an essential immunoregulator in the intestinal tract.

Management of Hirschsprung's disease in children with trisomy 21

Thirteen infants and children with trisomy 21 have been treated for Hirschsprung's disease since 1975. Clinical presentation of Hirschsprung's disease included constipation (five); neonatal intestinal obstruction (four); enterocolitis (three); and meconium plug syndrome (one). Additional associated congenital anomalies occurred in 10 patients, of which complex cardiac disease accounted for 25% of the defects. Seven children underwent definitive operation: Duhamel pull-through (four); Soave pull-through (two); and anal myectomy (one). Satisfactory continence occurred in all but one child. Enterocolitis developed in seven patients (54%): two at diagnosis of Hirschsprung's disease; three after colostomy; and two after pull-through. Five children died (38%): one from enterocolitis, two from cardiorespiratory failure after recovery from enterocolitis, and two from end-stage cardiac disease. Children with trisomy 21 can safely undergo definitive operation for Hirschsprung's disease but are at high risk for developing enterocolitis and complications of associated cardiac disease.

Role of surgical treatment in the management of complications of the gastrointestinal tract in patients with leukemia

The clinical course of patients with leukemia, specifically after treatment, is complicated by opportunistic infections, often derived from the gastrointestinal tract. Four hundred and thirty-eight patients with leukemia were treated at the Arizona Health Sciences Center from 1976 to 1985. Fifty-five (13 per cent) had 60 major gastrointestinal complications develop. Thirty-seven were treated medically with a mortality rate of 51 per cent, while 18 who were treated surgically had a 17 per cent mortality rate. These infections usually occur during induction or consolidation chemotherapy. Positive blood cultures and white blood cell counts of less than 2,500 per millimeter are a frequent occurrence. The most common complications of the gastrointestinal tract are enterocolitis, perirectal sepsis and bleeding. Because of the combined defects in phagocytosis (neutropenia), antibody production and cell mediated immunity, opportunistic infections (such as viral, fungal, parasitic or bacterial) are frequent and often lethal, despite routine antibiotic coverage. A protocol to identify a subset of patients with septic leukemia who may require emergency surgical treatment is vital since death in this group is most commonly from undiagnosed sepsis or progression of hematologic defects. This protocol should include repeated physical examinations, daily roentgenograms of the abdomen, liberal use of endoscopy, contrast roentgenography and computed tomography (CT) or ultrasound. Extensive surgical procedures can be safely carried out in patients with leukemia. The diagnosis of leukemia should not be a deterrent to emergency surgical exploration.

Neutropenic enterocolitis in adults with acute leukemia

Neutropenic enterocolitis has been previously described only by case reports and literature reviews. Of 499 adults with acute leukemia seen over a 23-year period (1962 to 1985), 13 cases (2.6%) of neutropenic enterocolitis have been reported. Eleven of these 13 patients were profoundly neutropenic (mean white blood cell count, 472/cu mm) and developed abdominal symptoms during either initial induction or relapse of acute leukemia. Histologic confirmation was available in ten cases, five cases after surgical resection and five cases at autopsy after nonoperative management. Three patients with isolated ileocecal inflammation without infarction at the time of surgery were successfully managed without resection. Five patients treated with surgery died four to 64 weeks postoperatively (mean survival, 21.6 weeks) of nonsurgical complications of leukemia. Three patients were still alive, one patient 42 months after right hemicolectomy and two patients five months after exploration only. All five patients managed medically died an average of 1.4 days (range, zero to four days) after the onset of abdominal pain. Survival in patients with acute leukemia who develop neutropenic enterocolitis is determined by early recognition and appropriate surgical exploration that can be expected to yield an acceptable operative mortality.