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    Default Typhlitis Pictures - Pediatric cases

    Pathophysiology
    Although the exact etiology and progression of neutropenic enterocolitis are unknown, profound neutropenia appears to be the common denominator. Many factors have been described that may potentially play a role in the pathogenesis of neutropenic enterocolitis, and they include the following:

    • Mucosal injury caused by cytotoxic drugs – However, mucosal injury can occur in the absence of cytotoxic drug therapy, and neutropenia itself can cause mucosal ulcerations.
    • Cecal distention – Whether primary or secondary to vinca alkaloids, cecal distention may compromise the blood supply, leading to further mucosal damage.
    • The use of antibiotics and steroids – These agents may contribute to an altered enteric bacterial flora and overgrowth of fungi.
    • Bacterial, and sometimes fungal invasion of the impaired bowel wall – These may result in transmural inflammation, leading to perforation and peritonitis. Bacteremia is a frequent complication, with less frequent fungemia.


    The pathologic process of neutropenic enterocolitis may involve the cecum alone, or it may extend to the ileum, ascending colon, or both. It is felt that cecal distensibility and limited blood supply may predispose the cecum to injury more often than other areas.

    United States
    The exact incidence and prevalence rates of neutropenic enterocolitis are unknown, because many patients survive and are never diagnosed with this condition. Also, because there is no gold standard of diagnosis for neutropenic enterocolitis, the inclusion criteria differ among studies.

    An autopsy study in children reported a prevalence rate of 24%, whereas a cohort study in children treated for acute myelogenous leukemia (AML) reported a frequency rate of 33%.A recent retrospective review of 1224 children treated for malignancy showed an incidence of only 1.4%, of which 53% were treated for leukemia. Data regarding neutropenic enterocolitis in adults are sparse. In one systematic review, a 5.3% pooled incidence rate was been reported in adults.

    International
    An even greater paucity of information regarding the international incidence and prevalence rates of neutropenic enterocolitis exists in the published literature.

    A study from India performed by Jain et al reported a frequency rate of 6.1% in 180 children undergoing chemotherapy for acute lymphocytic leukemia (ALL).
    A retrospective study from Turkey performed by Buyukasik et al reported an incidence rate of 6.5% for neutropenic enterocolitis in acute myeloid leukemia and 4.6% for neutropenic enterocolitis in acute lymphoblastic leukemia.Another Turkish study, a large prospective cohort study of adults, showed an incidence rate of 3.5%, which was significantly associated with acute leukemias and anthracycline administration in adults.

    Most recently, a large prospective study from Poland examined 297 adult patients following hematopoietic stem cell transplantation. They diagnosed neutropenic enterocolitis in 12% of patients using criteria of abdominal pain, diarrhea, and bowel wall thickening greater than 4 mm on abdominal sonography.

    Again, a lower incidence of 0.22% has been reported in the treatment of malignancy, not specifically leukemia.

    Physical
    Physical findings in patients with neutropenic enterocolitis vary depending on the severity of the disease and the presence or absence of complications.
    Typhlitis Pictures Pediatric cases attachment.php?s=2a8eb0dcd89f399029f3a93aafca5e73&attachmentid=332&d=1435865933

    • Abdominal distention, hypoactive bowel sounds, and a tympanitic abdomen may suggest an ileus.
    • The abdomen may be markedly tender, especially in the right lower quadrant.
    • The cecum may be palpated as a boggy mass.
    • Rebound tenderness and rigidity may suggest colonic perforation.
    • Shock may be present due to sepsis.


    Causes
    Although cytotoxic chemotherapeutic agents account for most cases of neutropenic enterocolitis, other conditions that may predispose some patients to develop this condition exist.

    • The cytotoxic chemotherapeutic agents include cytosine arabinoside, vinca alkaloids, and doxorubicin.
    • Other drugs that have been implicated anecdotally include paclitaxel, docetaxel, procainamide, sulfasalazine, 5-fluorouracil, vinorelbine, carboplatin, cisplatin, gemcitabine, and leucovorin.
    • There have been newly described cases of neutropenic enterocolitis associated with the monoclonal antibody alemtuzumab[19] as well as with pegylated interferon (PEG-INF) with ribavirin.
    • Other predisposing conditions for neutropenic enterocolitis include the following:
    • Myelodysplastic syndromes, multiple myeloma, and aplastic anemia
    • Solid organ and bone marrow transplantation
    • Acquired immunodeficiency syndrome (AIDS)
    • Cyclic neutropenia
    • Solid malignant tumors
    • Lymphomas


    Medical Care
    While there are practice guidelines available,no published randomized control trials comparing conservative medical therapy with surgical intervention in neutropenic enterocolitis exist; however, advocates for both types of therapy exist. The outcome appears to reflect the state of the underlying disease and other comorbidities at the time of clinical presentation rather than the treatment modality. Therefore, a uniform management strategy for neutropenic enterocolitis cannot be recommended. Individualize the approach to each patient. Early recognition of neutropenic enterocolitis in a patient who is neutropenic is paramount to a good outcome.

    References:

    http://emedicine.medscape.com/article/183791-treatment











    Attached Images  
    Last edited by Medical Photos; 09-01-2015 at 07:08 PM.

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  3. #2
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    no pictures
    realy appreciate if corrected this error
    thanks

  4. #3
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    were're the picture?

  5. #4

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    Sorry for this error. I attached the pictures

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