enterocolitis neutropénica
DESCRIPTION
Enterocolitis NeutropeniaDr Carlos VallejoTRANSCRIPT
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Carlos Eduardo Vallejo BocanumenResidente Medicina de Urgencias
U de A
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1933. Cooke – hemorragia submucosa y apendicitis perforada.
1969. Amromin – 69 casos de EN. Leuc. y Linf.
Cunningham SC, Fakery K, Bass BL, et al. Neutropenic enterocolitis in adults:
case series and review of the literature. Dig Dis Sci 2005;50:215–20.
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EN independiente de respuesta a Qtx.
Excelente respuesta a Qtx pre EN
Dolor abdominal, Distensión, Leucopenia
Necrosis Intestinal
Invasión bacteriana en pared intestinal
Mortalidad del 100%
Cunningham SC, Fakery K, Bass BL, et al. Neutropenic enterocolitis in adults:
case series and review of the literature. Dig Dis Sci 2005;50:215–20.
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Incidencia: 5.3% / Tto Ca hematologico, Anemia
Aplastica
5.6% / Ptes con Tx organo solido
Gorschluter M, Mey U, Strehl J, et al. Neutropenic enterocolitis in adults: systematic
analysis of evidence quality. Eur J Haematol 2005;75(1):1–13.
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Criterios diagnósticos?
Superposición de hallazgos
Estandar de Oro: Estudio histologico*
Gorschlu¨ ter M, Mey U, Strehl J, et al. Neutropenic enterocolitis in adults: systematic
analysis of evidence quality. Eur J Haematol 2005;75:1–13.
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Condiciones.1.Paciente Neutropénico
2. Infección Invasiva
3.La inflamación compromete el Intestino
Gorschlu¨ ter M, Mey U, Strehl J, et al. Neutropenic enterocolitis in adults: systematic
analysis of evidence quality. Eur J Haematol 2005;75:1–13.
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Paciente Neutropénico
Quimioterapia reciente
Dolor abdominal
Fiebre
Robert L. Cloutier, MD. Neutropenic Enterocolitis. Emerg Med Clin N Am
27 (2009) 415–422
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Localizado / Cuadrante inferior derecho◦ Apendicitis?◦ Tiflitis◦ Otros
Generalizado◦ Rebote?
Robert L. Cloutier, MD. Neutropenic Enterocolitis. Emerg Med Clin N Am
27 (2009) 415–422
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Clínica común a otras enfermedades
No solo en pacientes con Cáncer◦ Granulocitopenias por otras causas
No hay criterios diagnósticos
NEUTROPENIARobert L. Cloutier, MD. Neutropenic Enterocolitis. Emerg Med Clin N Am
27 (2009) 415–422
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QUIMIOTERAPEUTICOSPaclitaxel Vincristin
Docetaxel Doxorubicin
Gemcitabina Cyclophosphamida
Arabinosida 5 –Fluorouracil
Cytosin Leucovorin
DaunorubicinRobert L. Cloutier, MD. Neutropenic Enterocolitis. Emerg Med Clin N Am
27 (2009) 415–422
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AINE’s Nafcilina Anemia Aplastica Neutropenia Cíclica Supresión medular
por Tx renal o de MO.
LES VIH Talasemia menor Sindrome de Felty
Robert L. Cloutier, MD. Neutropenic Enterocolitis. Emerg Med Clin N Am
27 (2009) 415–422
Gorschlu¨ ter M, Mey U, Strehl J, et al. Neutropenic enterocolitis in adults: systematic
analysis of evidence quality. Eur J Haematol 2005;75:1–13.
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CGP BGN Clostridium spp Enterococos CMV Candida spp
Davila ML. Neutropenic enterocolitis. Curr Opin Gastroenterol 2006;22:44–7.
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TAC de abdomen◦ Engrosamiento de la pared intestinal, neumatosis,
Nodularidad
Ultrasonido ◦ Engrosamiento de la pared intestinal
Rx de Abdomen◦ Aire en colon derecho + Neumotosis
Robert L. Cloutier, MD. Neutropenic Enterocolitis. Emerg Med Clin N Am
27 (2009) 415–422
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TAC AbdominalDxs diferenciales: Colitis por C. difficile,
Enfermedad Injerto vs Huesped
Colon derecho y Ciego 75% en ENCompromiso intestino delgado, 66% en ENEstriación grasa mesentérica.
Kirkpatrick ID, Greenberg HM. Gastrointestinal complications in the neutropenic patient: characterization and differentiation with abdominal
CT. Radiology 2003; 226:668–74.
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US permite evaluar engrosamiento de pared intestinal
Diagnósticos diferenciales◦ Apendicitis◦ Pancreatitis◦ Intususcepción.
Falsos positivos
Robert L. Cloutier, MD. Neutropenic Enterocolitis. Emerg Med Clin N Am
27 (2009) 415–422
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1450 ptes Leucemia.
88 Síntomas de EN
44 US + para engrosamiento pared intestinal
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Conclusiones:
US es util para el dx del ENUS es util como factor pronostico en EN
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Tratamiento Quirúrgico
Tratamiento Médico
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Antibioticoterapia
Estimulador de Formador de Colonias de Granulocitos (G – CFS)
Descanso intestinal
Soporte hemodinamico
Robert L. Cloutier, MD. Neutropenic Enterocolitis. Emerg Med Clin N Am
27 (2009) 415–422
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Atb´s amplio espectro Monterapia
◦ Ureidopenicilinas◦ Carbápenem
Duoterapia◦ B – Lactamico antipseudomonico + aminglicosido◦ Cefalosporina 3ª o 4ª + Metronidazol
Gorschlu¨ ter M, Mey U, Strehl J, et al. Neutropenic enterocolitis in adults: systematic
analysis of evidence quality. Eur J Haematol 2005;75:1–13.Clinical Practice Guideline for the Use of Antimicrobial Agents in Neutropenic
Patients with Cancer: 2010 Update by the Infectious Diseases Society of America; CID 2011:52 (15 February)
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Clinical Practice Guideline for the Use of Antimicrobial Agents in Neutropenic Patients with Cancer: 2010 Update by the Infectious Diseases Society of
America; CID 2011:52 (15 February)
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Cuando pensar en hongos?◦ Neutropenicos Profundos◦ 5 > dias de fiebre sin mejoria◦ Dosis adeduadas de Atbs
Anfotercina B ó Equinocandina
Gorschlu¨ ter M, Mey U, Strehl J, et al. Neutropenic enterocolitis in adults: systematic
analysis of evidence quality. Eur J Haematol 2005;75:1–13.
Clinical Practice Guideline for the Use of Antimicrobial Agents in Neutropenic Patients with Cancer: 2010 Update by the Infectious Diseases Society of
America; CID 2011:52 (15 February)
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Leucocito < 100 / ml Enfermedad severa Falla multisistemica Neumonia Infeccion por hongos Hipotension
Robert L. Cloutier, MD. Neutropenic Enterocolitis. Emerg Med Clin N Am
27 (2009) 415–422Kouroussis C, Samonis G, Androulakis N, et al. Successful conservative
treatmentof neutropenic enterocolitis complicating taxane-based chemotherapy:
a report of five cases. Am J Clin Oncol 2000;23(3):309–13.
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Omeprazol
Reposo intestinal
Nutricion parenteral Total
Gorschlu¨ ter M, Mey U, Strehl J, et al. Neutropenic enterocolitis in adults: systematic
analysis of evidence quality. Eur J Haematol 2005;75:1–13.
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Diarrea pos Qtx y pos Rtx
Colitis por Clostridium difficile*◦ No relación con Atb
Mucositis
Gorschlu¨ ter M, Mey U, Strehl J, et al. Neutropenic enterocolitis in adults: systematic
analysis of evidence quality. Eur J Haematol 2005;75:1–13.
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“… cambio en tendencia de desenlaces, gracias a identificación temprana e intervención agresiva.”
Robert L. Cloutier, MD. Neutropenic Enterocolitis. Emerg Med Clin N Am
27 (2009) 415–422
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