Diarrhea in cancer patients with neutropenia

SUMMARYAlthough diarrhea is a frequent complication of cytotoxic chemotherapy, its true incidence, risk factors and clinical course have not been investigated prospectively. Diarrhea was defined as the passage of soft or liquid stool t.i.d. or more, or an increase of at least twice the number of baseline bowel movementsA neutropenic episode is defined as starting from the first day of neutropenia (ANC <500 per mm3 or ANC <1000 with predicted to decrease <500 per mm3) until two successive ANCs >500 per mm3.Neutropenic enterocolitis is a specific disease entity, usually manifesting itself with diarrhea. It is thought to be associated with chemotherapy-induced mucosal injury, followed by a superinfection usually by Gram-negative bacteria and may lead to bacteremia.Abdominal ultrasonography is one of the most important diagnostic studies for neutropenic enterocolitis. Findings include thickening of the bowel wall that produces a target sign. Other features include areas of different echogenity caused by edema, necrosis and/or circumscript hemorrhages. Intramural air indicates an infection with anaerobic bacteria.This study was held over one year period (from September 2009 to September 2010) at Zagazig university hospital, pediatric department, heamatology and oncology unite and medical microbiology and immunology unit on 50 children who are divided into 2 groups:Group (1): 8 patients diagnosed as neutropenic enterocolitis (1male & 7 females), their age ranged from 7 month to 12 years with mean values of 4.83.88 years.Group (2): 42 patients with neutropenic diarrhea of malignant disease rather than neutropenic enterocolitis (20 male & 22 female), their age ranged from 9 month to 14 years with mean value of 6.03.5 years.Episodes of diarrhea associated with neutropenia were more common during the induction phase in our patients. The duration and severity of neutropenia was significantly associated with occurrence of typhlitis.Cytrabine was the most implicated chemotherapeutic agent in group (2), while in group (1) methotrexate was the most commonly implicated chemotherapeutic agent. Methotrexate and mitoxantrone were associated significantly with the occurrence of typhlitis.In our study, significant clinical findings in patients with typhlitis are right lower quadrant pain, fever and abdominal tenderness.Metabolic acidosis was frequent complication of diarrhea with neutropenic enterocolitis.Regarding microbiological evaluation of stool samples results in Group (1) revealed 2 cases with negative stool culture. Candida was the most commonly revealed organism in this group (2), followed by Klebsiella (2), E.coli (1) and Enterohemorgic E.coli (EHEC).In patients with neutropenic enterocolitis bowel wall thickness was 5.20.7mm and in these patients all other diagnostic sonographic criteria were statistically significant regarding bowel wall dilatation, regularity, pneumatosis intestinalis and mucosal enhancement.CONCLUSIONIn conclusion, this study revealed that diarrhea was a common finding in neutropenic patients. Gram negative bacteria and candida species were predominating in stool culture results. Duration and severity of neutropenia carry a great risk for development of neutropenic enterocolitis. Neutropenic enterocolitis should be highly anticipated during induction.Fever, abdominal pain and tenderness are considered red alerts for the oncologists in any neutropenic patients. Abdominal ultrasonography is the corner stone in confirming the diagnosis of typhlitis being rapid, non-invasive yet a yielding tool. Increased bowel wall thickness is the most important sonographic finding.