GI Radiography


Case 20 :
Known case of leukemia, post chemotherapy status, presents with right lower quadrant pain.
What is the diagnosis?
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Diagnosis:

Cecal typhilitis

Discussion:

Typhlitis means inflammation of the cecum. In 1960, Bierman and Amronin first coined the term "ileocecal syndrome" to describe inflammation and/or necrosis of the cecum, appendix, and/or ileum in patients with leukemia. Typhlitis subsequently has been associated with aplastic anemia, lymphoma, AIDS, and immunosuppression following renal transplantation or during treatment of malignancy.

Pathologically, typhlitis represents inflammation and/or necrosis of the cecum, appendix, and/or ileum. The etiology of typhlitis is unknown, but its pathogenesis is multifactorial. Profound neutropenia, with total neutrophil counts of less than 1000/mm3, appears to be a universal predisposing factor. Mucosal injury from cytotoxic drugs plays an important role in the typhlitis observed during chemotherapy.

Cecal distension in typhlitis may impair the blood supply, leading to mucosal ischemia and ulceration. Infection may be involved, especially cytomegalovirus. Bacterial invasion leads to transmural penetration and, ultimately, perforation. Mucosal and submucosal necrosis can result in intramural hemorrhage. Neoplastic infiltration may be involved in some patients.


CT Findings
The maximum normal colonic wall thickness on CT is 3 mm. When the colon is distended with stool, fluid, or oral contrast, the normal colonic wall is nearly imperceptible. Pericolonic fat should demonstrate homogeneous fat attenuation. Typhlitis usually is confined to the cecum, appendix, and terminal ileum; however, it can cause a pancolitis extending distally from the cecum. CT demonstrates circumferential and occasionally eccentric low-attenuation colonic wall thickening and cecal distension. High attenuation within the thickened colonic wall may represent hemorrhage, and inflammatory pericolonic stranding of mesenteric fat is common.

CT readily identifies complications, including pneumatosis coli, pneumoperitoneum, pericolonic fluid collections, and abscess. These complications may require urgent surgical management.

References
http://www.emedicine.com/radio/topic869.htm
archpedi.ama-assn.org/issues/v154n6/fpdf/prc2898.pdf


Dr. Bhujang Pai, Hinduja Hospital, Mumbai