Neutropenic enterocolitis (typhlitis)
Neutropenic enterocolitis (typhlitis) is necrotizing inflammation of the cecum and adjacent bowel in a profoundly neutropenic patient, presenting with fever and right lower quadrant pain during chemotherapy nadir. Diagnosis rests on CT bowel wall thickening in the correct clinical setting. Treatment is bowel rest plus broad-spectrum antibiotics with anaerobic coverage, for example piperacillin-tazobactam plus metronidazole, with surgery reserved for perforation or uncontrolled bleeding.
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What this article covers
- Overview
Neutropenic enterocolitis, also called typhlitis, is a necrotizing inflammation of the cecum and adjacent bowel that develops in a patient with profound, treatment-induced neutropenia.
- Epidemiology
Population: Occurs almost exclusively in patients receiving intensive cytotoxic chemotherapy, most often for acute leukemia, and in patients undergoing hematopoietic stem cell transplant conditioning.
- Risk factors
Profound, prolonged neutropenia: ANC less than 500/microL, especially less than 100/microL, for more than 7 days carries the highest risk.
- Pathophysiology
Cytotoxic chemotherapy injures the rapidly dividing mucosal epithelium, breaking down the barrier that normally separates luminal flora from the bowel wall.
- Clinical features
Fever: Present in essentially all patients, often the presenting sign, occurring during the expected chemotherapy nadir.
- Differential diagnosis
Acute appendicitis: Also causes right lower quadrant pain and fever, but shows a discrete inflamed appendix on imaging rather than circumferential cecal and pericecal wall thickening, and is not tied to a chemotherapy nadir.
- Diagnosis
The diagnosis is established clinically, in a neutropenic patient (ANC generally less than 500/microL) with fever and abdominal pain and no other explanation for those findings; no single blood test confirms it by itself.
- Management
Initial management is medical for most patients, with surgery reserved for defined complications.
- Complications
Bowel perforation: The most feared complication, presenting with new peritonitis or free air on imaging, and the leading indication for emergency surgery.
- Prognosis
Outcomes depend on whether the episode is controlled with medical therapy alone or requires surgery, and on how quickly the neutrophil count recovers.
- Prevention
Antimicrobial prophylaxis during anticipated prolonged neutropenia: A fluoroquinolone or a third-generation cephalosporin plus a mold-active azole (posaconazole, voriconazole, or isavuconazole) is…
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- Neutropenia
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- Ischemic colitis
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- Acute appendicitis
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