II. Epidemiology
- Rare, but catastrophic cause of Acute Abdominal Pain in patients on Chemotherapy
III. Pathophysiology
- Results from Chemotherapy-induced GI mucosa toxicity (and Neutropenia) with subsequent superinfection
- Necrotizing colitis involving cecum (but can also affect Large Bowel and proximal Small Bowel)
- Similar process as with Necrotizing Enterocolitis in newborns
IV. Risk Factors
- HIV Infection
- Aplastic Anemia
- Immunosuppression
- Hematologic Malignancy (more than with solid tumors)
V. Symptoms
- Fever
- Right Lower Quadrant Abdominal Pain
- Abdominal cramping
- Diarrhea
- Gastrointestinal Bleeding
VI. Signs
- Typical presentation is with a toxic or septic, ill appearing patient
- Abdominal Distention
VII. Differential Diagnosis
VIII. Imaging
-
Abdominal CT
- Bowel wall thickening and intramural edema (infarcted bowel)
- Avoid tests which risk colon perforation
- Barium Enema
- Endoscopy
IX. Management
- Emergency Surgical Consultation for perforation
- Surgical management is based on size of infarcted bowel
- Supportive care
-
Bowel rest
- Consider Total Parenteral Nutrition
- Broad spectrum IV antibiotics (to cover Gram Negative and Anaerobic Bacteria)
- First-Line Agents
- Piperacillin-Tazobactam (Zosyn) 4.5 g IV every 6 hours OR
- Imipenem-Cilastin 500 mg IV every 6 hours OR
- Meropenem 2 g IV every 8 hours
- Alternative Agents
- Cefepime 2 g IV every 8 hours AND
- Metronidazole 500 mg IV every 8 hours
- Additional agents to consider in refractory cases
- Candida coverage (e.g. Echinocandin)
- Clostridium difficile coverage (test in all cases)
- First-Line Agents
X. Prognosis
- High mortality
XI. References
- Aurora and Herbert in Majoewsky (2013) EM:Rap 13(10): 1-4
- Cloutier (2010) Hematol Oncol Clin North Am 24(3): 577-84 [PubMed]
- Higdon (2006) Am Fam Physician 74:1873-80 [PubMed]
- Nesher (2013) Clin Infect Dis 56(5):711-7 [PubMed]
- Zuckerman (2012) Blood 120(10): 1993-2002 [PubMed]