Consider the possibility of typhlitis in cancer patients who present with symptoms suggestive of appendicitis

Consider the possibility of typhlitis in cancer patients who present with symptoms suggestive of appendicitis: Excerpt from Avoiding Common Pediatric Errors

Author: Cynthia Gibson, MD

What to Do - Interpret the Data

Typhlitis refers to a necrotizing colitis involving the cecum or the cecum and appendix, and is found in leukemic children. The term neutropenic enteropathy is also used to refer to these clinical findings. The vaguely defined clinical diagnosis of typhlitis is difficult, but frequent symptoms include abdominal pain, fever, tenderness on exam, and diarrhea. Typhlitis and appendicitis appear to be equally common in the young leukemic patient with right lower quadrant signs of peritoneal irritation. The classical signs of peritoneal irritation can be found in these patients despite their neutropenia and immunosuppressed condition, and have the same implications as in the nonleukemic patient. Plain radiographs are nonspecific but may demonstrate a fluid-filled mass like density in the right lower quadrant, distension of adjacent small bowel loops, and thumb printing. Free intraperitoneal air and pneumatosis coli rarely are observed. The early use of computed tomography scanning helps to facilitate the diagnosis and may provide the ability to differentiate typhlitis from other abdominal diseases for which surgery would be indicated. In typhlitis, computed tomography scan demonstrates cecal distention and circumferential thickening of the cecal wall, which may have low attenuation secondary to edema.

The greatest risk to these patients is from progressive local and systemic infection.Thepathogenesisappearstobececaldistension,whichmayimpair the blood supply, lead to mucosal ischemia and ulceration. Infection may be involved, especially cytomegalovirus. Bacterial invasion leads to transmural penetration and, ultimately, perforation then sepsis. The average mortality rate from sepsis is 40% to 45%.

Diagnosis of this disorder without pathologic examination is speculative and the differentiation from appendicitis is unclear. Operative findings range from simple edema of the cecum to a frankly necrotic and perforated cecum.Thepreoperativedifferentiationbetweenappendicitisandtyphlitisis difficult.Pediatriccancerpatientswithtyphlitiscan betreatedcarefullynonoperatively, with bowel rest, antibiotics, and supplemental nutrition. Usual indications for surgery (i.e., perforation, clinical deterioration) still should be used.

Suggested Readings

McCarville MB, Adelman CS, Li C, et al. Typhlitis in childhood cancer. Cancer. 2005;104(2): 380–387.
Schlatter M, Snyder K, Freyer D. Successful nonoperative management of typhlitis in pediatric oncology patients. J Pediatr Sur. 2002;37(8):1151–1155.
SkibberJ,MatterGJ,PizzoPA,etal.Rightlowerquadrantpaininyoungpatientswithleukemia. A surgical perspective. Ann Surg. 1987;206(6):711–716.

Book Source Details

• Book Title: Avoiding Common Pediatric Errors
• Author(s): Anthony D Slonim MD, DrPH; Lisa Marcucci MD
• Year of Publication: 2008
• Copyright Details: Avoiding Common Pediatric Errors, Copyright © 2008 Lippincott Williams & Wilkins.

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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.

More About This Book: Title: Avoiding Common Pediatric Errors Authors: Anthony D Slonim MD, DrPH; Lisa Marcucci MD Publisher: Lippincott Williams & Wilkins Copyright: 2008 ISBN: 0-7817-7489-6

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