Cholecystitis in neutropenic patients: Retrospective study and systematic review
Introduction
Abdominal infections are life-threatening complications in neutropenic patients. Patients with leukemia undergoing aggressive chemotherapy are most often affected [1]. It is a diagnostic challenge for the physician to dissect the cause of abdominal symptoms (infectious and non-infectious) in these patients. Neutropenic enterocolitis is the most important entity. Acute cholecystitis is much rarer in neutropenic patients, but several, mostly anecdotal reports, suggest that this infection is of relevance in neutropenia. However, a systematic analysis describing a larger cohort of patients is lacking. In the IDSA guidelines for the use of antimicrobial agents in neutropenic patients with cancer no specific treatment recommendation concerning neutropenic cholecystitis is provided [2]. A major portion of the afflicted neutropenic patients suffer from acalculous cholecystitis similar to other groups of patients with very severe underlying diseases and different from standard risk patients [3], [4]. This study provides the largest published case series concerning neutropenic cholecystitis combined with a systematic review of the literature. It summarizes the clinical picture, diagnostic procedures, therapy and prognosis in these patients.
Section snippets
Patients and methods
A retrospective analysis of patients with cholecystitis in neutropenia treated in the leukemia ward and the intensive care unit of our university medical center from April 1991 to December 2004 was performed. Over this 12-year period all 1607 courses of myelo-suppressive chemotherapy administered in patients with acute leukemia or aggressive lymphoma (courses of intensive chemotherapy with a duration of neutropenia of at least 5 days only) were screened. Parts of this observation period (April
Patients in Bonn
Nine episodes of cholecystitis in nine patients treated in the leukemia ward and the intensive care unit of our university medical center with acute leukemia or aggressive lymphoma (following high dose-chemotherapy) were identified within a period of 12 years and 8 months (Table 2). During this period 1849 admissions of patients with these underlying diseases were recorded and 1607 cycles of myelosuppressive chemotherapy with a duration of neutropenia of at least 5 days were administered to
Discussion
Abdominal infections are life-threatening complications for patients with profound neutropenia. Most cases have been reported in patients with acute leukemia following chemotherapy [1]. Neutropenic enterocolitis is the most important entity. Acute cholecystitis is interestingly uncommon in neutropenic patients, but several mostly anecdotal reports suggest that this infection is also of relevance in neutropenia.
Our study reveals several important results: (1) In our own patients a frequency of
Acknowledgments
This study was supported by Leukämie-Initiative Bonn e.V. The authors declare that they have no conflicts of interest.
Contributions. MG was responsible for the design and the statistical analysis of the project; MG and AG drafted the manuscript; MG, JS, MS and CL extracted and checked the data; UM and TS provided statistical and methodological input and contributed to the manuscript. All authors revised and approved the manuscript.
References (41)
- et al.
Acute acalculous cholecystitis in the critically ill patient
Am J Surg
(1983) Acute acalculous cholecystitis
Am J Surg
(1981)- et al.
Gallbladder wall thickening: an in vitro sonographic study with histologic correlation
Acad Radiol
(1994) - et al.
Ultrasound and CT evaluation of emergent gallbladder pathology
Radiol Clin North Am
(2003) - et al.
Intraabdominal operations in patients with leukemia
Am J Surg
(1988) - et al.
Acute cholecystitis after autologous bone marrow transplantation for acute myeloid leukemia
Ann Oncol
(1995) - et al.
Neutropenic enterocolitis in adults: systematic analysis of evidence quality
Eur J Haematol
(2005) - et al.
2002 guidelines for the use of antimicrobial agents in neutropenic patients with cancer
Clin Infect Dis
(2002) - et al.
Severe abdominal infections in neutropenic patients
Cancer Invest
(2001) - et al.
Abdominal infections in patients with acute leukaemia: a prospective study applying ultrasonography and microbiology
Br J Haematol
(2002)
The Oxford Centre for evidence-based medicine levels of evidence
Ultrasound scan to detect acalculous cholecystopathy in immunocompromised hosts with unexplained fever
Haematologica
Early detection by ultrasound scan of severe post-chemotherapy gut complications in patients with acute leukemia
Haematologica
Does this patient have acute cholecystitis?
JAMA
Acalculous acute cholecystitis in leukemia
J Clin Gastroenterol
CT of a thickened-wall gall bladder
Br J Radiol
Septic acute cholecystitis
Scand J Gastroenterol
Gangrenous cholecystitis secondary to Candida tropicalis infection in a patient with leukemia
Clin Infect Dis
Cholecystitis as the presenting manifestation of acute myeloid leukemia: report of a case
Am J Hematol
Cited by (29)
Cholecystectomy in patients with hematologic malignancies
2022, American Journal of SurgeryCitation Excerpt :Neutropenic hematology patients develop cholecystitis at a frequency of 0.4% per neutropenic episode.11 In a report of 9 such patients treated from 1991 to 2004, 6 underwent surgery, 2 died postoperatively, and 4 died during their treatment for cholecystitis, but none had cholecystitis as the primary cause of death.11 These authors' literature review identified 45 patients and found that pooled mortality in surgically treated patients was 22%, compared to 36% for those managed conservatively.
Appendectomy and Cholecystectomy Outcomes for Pediatric Cancer Patients with Leukopenia: A NSQIP-pediatric Study
2021, Journal of Surgical ResearchCitation Excerpt :In pediatric cancer patients, small cohort studies have shown thatan appendectomy is well tolerated in the setting of neutropenia.1,6 A retrospective series of 9 neutropenic patients with cholecystitis suggested that treatment should be individualized.16 However, pediatric studies are limited by small sample size and single center cohorts.
Management of surgical challenges in actively treated cancer patients
2017, Current Problems in SurgeryCitation Excerpt :The definition of neutropenia varies, but authors cite an absolute neutrophil count (ANC) of less than 0.5-1.5 × 109 cells/L as a cutoff.161,162,164,165 The decision to operate in neutropenia has been associated with a significant postsurgical mortality with rates anywhere from 34%-60%.161,162,166,167 Depending on the chemotherapy regimen and the number of lines of chemotherapy the patient has received, duration of neutropenia can last anywhere from several weeks to months.
Management of anorectal and intra-abdominal infections in the neutropenic cancer patient
2015, Current Problems in CancerCitation Excerpt :Patients diagnosed with acute cholecystitis are more likely to have acalculous cholecystitis (67%) than those without neutropenia (5%). Patients with neutropenia diagnosed with acute cholecystitis have a high mortality rate of 26% but only 14% of the deaths were primarily caused by the complications of the cholecystitis.46 Surgical intervention has been associated with a nearly 50% mortality rate and should be reserved for perforation or pneumoperitoneum.
Acute acalculous cholecystitis complicating chemotherapy for acute myeloblastic leukemia
2015, Leukemia Research ReportsCitation Excerpt :ACC is a relatively rare complication in these patients’ population. It’s reported in 0.4% among all neutropenic episodes of patients with acute leukemia or aggressive lymphoma undergoing myelosuppressive chemotherapy [3]. Clinically, AAC is difficult to diagnose because the findings of right upper-quadrant pain, fever, leukocytosis, and abnormal liver tests are not specific.