Typhlitis
A Common Cause Of Abdominal Pain Following Chemotherapy

Definition, Causes, Diagnosis And Treatment Of Caecal Inflammation, Also Called Cecitis, Enterotyphlitis Or Enterocolitis

Typhlitis was first reported in the 1970s in children undergoing chemotherapy for leukaemia. Over the last few years, there is increasing recognition of this condition and repeatedly well documented to occur in both children and adults and in those with other forms of cancer who are on chemotherapy.

Some 30 years ago, a diagnosis of this condition was thought to be terminal. Thankfully, with early recognition, treatment is now possible. But what is enterocolitis or typhlitis?

Typhlitis Defined

Our large intestine or bowel starts as a big oblong pouch called the caecum (or cecum if you are American), into which the small intestines empties. On the blind end of the caecum is the appendix. The caecum continues upward as the first part of the colon referred to as the ascending colon on the right lower abdomen. It continues upwards towards the right upper abdomen, where it curves towards the left just under the right breast area into the part of the large intestine called the transverse colon. This then again, curves downwards under the left breast area as the descending colon, and continues as the sigmoid colon and into the pelvis, continuing into the rectum and anus.

Inflammation of that part of the large intestines called the caecum is called cecitis or caecitis, also referred to as typhlitis. The inflammation could spread to include part of the adjoining small intestines (that is why it is sometimes referred to as entero (small intestine) colitis (colon inflammation) or enterocolitis.

It is a common cause of right lower abdominal pain, loose stools and low grade fever in patients on intensive chemotherapy, or in those with low immunity and low white blood cell count or certain types of infections.

Causes

The exact cause of typhlitis is unknown. It is however believed by medical investigators to be due to severe inflammation and breakdown in wall of the lumen of the cecum and surrounding intestines, by very intense level of chemotherapy, or from certain infections.

It is a condition more commonly seen in children on chemotherapy for acute leukaemia and increasingly in adults with other forms of cancer.

It is also believed that the steroids used along side chemotherapy in the treatment of such cancers could contribute to the emergence of this condition.

This condition is not found with the use of all forms of chemotherapy medications. It is believed that this inflammation of the caecum is more common in those who are on chemotherapy treatment with the following medications:

Apart from chemotherapy, studies have also revealed that those with certain types of infections like fungal infection, or yersina infection and who are immuno-compromised with conditions like HIV / AIDs or other forms of immune problems could develop caecitis.

What Are The Symptoms Of This Condition

• Are you currently on chemotherapy treatment, or have you just completed a course of chemotherapy within the last two weeks?
• Do you have a dull to sharp continuous ache in the right lower abdomen, perhaps spreading upwards towards the middle right abdomen or central abdomen?
• Does movement or pressure on the right lower abdomen or movement makes this pain worse?
• Do you feel somehow mildly or moderately unwell with feels of hot and cold or worsening of your appetite
• What about your bowel motions? Have they become looser in the last few days? Is there blood your stool?
• Are you feeling nauseated and even vomited?

If you are on chemotherapy and have a combination of any of the above symptoms, it is likely that you are suffering with cecitis or typhlitis. Seek immediate medical attention. This condition could be life threatening if not diagnosed and treated in time.

How Common Is Typhlitis

Enterotyphlitis or neutropaenic enterocolitis or caecitis is a condition believed to occur more commonly in those having chemotherapy or who just finished chemotherapy within the last two weeks. It is very rare otherwise. The following represents how common this condition is:

• About 3 to 4 children out of every 10 treated for certain forms of leukaemia (Acute lymphoblastic leukaemia - ALL) and children and adults with acute myeloid leukemia - AML, representing about 35% of such patients will have typhlitis.
• The older the child, the more likely is condition
• For adults on chemotherapy, up to 6 in a 100 could develop this condition, especially if their treatment was aggressive
  
• The more intensive and aggressive the chemotherapy treatment is, the increased in the likelihood of developing cecitis.
  

Diagnosis

To make a diagnosis of typhlitis, your doctor will need to get a full story of the symptoms you have, will need to examine you and then do some blood tests and scans.

The story your doctor will want to know include:

• That you have been on chemotherapy for a form of cancer
• The name of the chemotherapy medicine if you can remember it or have the record - most times, a doctor should be able to get this information from your specialist or oncologist treating you
• The symptoms you have including a right lower abdominal pain, when exactly did this pain start, how bad is it on a scale of 0 to 10, does the pain spread to any other place in your abdomen, what makes the pain worse, what makes it better, is there any associated problems like feeling nauseated or vomiting?
• What is you stool like - is it loose? Any blood or mucus in the stool?
• What about fever? Do you feel "washed out" and feeling hot and cold?
• What's your energy level like - being on chemotherapy in it self is draining, but if you now have typhlitis as well, it makes you feel even more tired and unwell

The examination will be thorough. Your doctor will want to check your temperature, take a look at your eyes to see if you are pale or jaundiced, and have your pulse, blood pressure and chest checked. The examination will then be focused on your abdomen. Your doctor will want to feel your abdomen to find out where hurts most, and then listen for the sounds of your bowels. It may be necessary to check your back passage (rectal examination) and your groin too.

The most important of the blood tests you need to do is your full blood count (complete blood count in North America), to check your white blood cells as well as your haemoglobin and platelet levels. Other blood tests are routinely done to check your liver, kidney, and inflammatory markers (CRP and ESR).

If your neutrophil - white blood cell count is very low, in the presence of a right lower abdominal pain and you are on chemotherapy, you have cecitis until proven otherwise!

The diagnosis can then be confirmed with a CT scan.
The CT scan typically shows a caecum with thickened wall with free fair trapped between the cecum and coils of bowels, all cramped together.

Where CT does not exist, the diagnosis of typhlitis can also be made on ultrasound scan along side a very typical story.

Treatment

Once diagnosis of caecitis is made, the treatment is often straight forward, and it generally involve:

• Admission into hospital
• Your chemotherapy may be stopped to prevent further deterioration
  
• You will be asked to have nothing to eat or drink to help rest the bowels so that recovery is encouraged
• Fluids will be given through the veins to replenish lost fluids and also provide vital nutrition and energy
• Adequate pain control and anti-sickness medicines if needed
• Sometimes, a tube may be passed down teh nose into teh stomach to help prevent vomiting and further help to rest the bowels
  
• Antibiotics
• Antifungals in some cases
• Close monitoring to see that the infection is not spreading and something more drastic is not needed
• If things seems to be getting worse, surgery may be required. But this is not often the case.
  

Prevention

There is no way to determine who will suffer with typhlitis or not. The best prevention is to be very alert to this condition if you are on chemotherapy. Should you have any pain on your lower right abdomen not settling after a day, and it is best to check with your doctor. At least if you have developed inflammation of the caecum, it would be picked up in time and treatment out come will be quicker and better.

Many experts believe that if you are on chemotherapy, there are things you could do to help prevent or reduce the effects of chemotherapy. Various herbs and supplements have been advocated.

References:

• Shahani L. Typhlitis: a neutropenic complication - BMJ Case Rep. 2012 May 30;2012. pii: bcr0220125815. doi: 10.1136/bcr.02.2012.5815. Department of Internal Medicine, Southern Illinois University School of Medicine, Springfield, Illinois, USA.
• Cunningham SC, Fakhry K, Bass BL, Napolitano LM. Neutropenic Enterocolitis in adults: case series and review of the literature. Dig Dis Sci 2005; 50:215.
• Pediatric Oncology Nursing: Advanced Clinical Handbook By Deborah Tomlinson, Nancy E. Kline. Springer, 2005 - 450 pages
• Acute Care Oncology Nursing E-Book By Cynthia C. Chernecky, Kathleen Murphy-Ende. 2011. Page 562
  

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Last Updated: 12.12.12

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