Typhlitis: Symptoms, Types, Causes and Treatment

Typhlitis, also known as neutropenic enterocolitis, is a serious and potentially life-threatening inflammatory condition of the cecum (the first part of the large intestine). Most commonly, it affects individuals with weakened immune systems—especially those undergoing chemotherapy for leukemia or other malignancies. This article explores the symptoms, types, causes, and treatment approaches to typhlitis, synthesizing evidence from recent medical literature to provide a comprehensive, patient-centered overview.

Symptoms of Typhlitis

Recognizing the symptoms of typhlitis is critical, as timely intervention can mean the difference between recovery and significant complications. Because typhlitis often occurs in immunocompromised individuals, such as patients undergoing chemotherapy, its onset may be subtle but can rapidly progress to severe illness.

Symptom	Description	Frequency/Severity	Source(s)
Abdominal Pain	Usually in the right lower quadrant	Very common, severe	1 2 3 6
Fever	Persistent, may be high	Very common	1 2 3 6
Diarrhea	Watery or bloody	Common, can be severe	1 2 3 6
Nausea/Vomiting	Associated with abdominal symptoms	Common	2 6
Abdominal Distension	Swelling of the abdomen	Less common	2 6
Gastrointestinal Bleeding	Blood in stool or vomit	Variable, can be severe	1 6
Hypotension	Low blood pressure, shock	May signal severity	2
Peritonitis	Signs of abdominal infection	Severe, less common	2 6

Table 1: Key Symptoms of Typhlitis

Abdominal Pain and Tenderness

Abdominal pain, frequently localized to the right lower quadrant, is the hallmark of typhlitis. This pain is often severe and may be accompanied by marked tenderness upon palpation. In many cases, the pain intensifies rapidly and does not respond to typical analgesics, a red flag for clinicians dealing with immunocompromised patients 1 2 3 6.

Fever

Fever almost always accompanies typhlitis and is often the first symptom noticed. In neutropenic patients, any fever should be taken seriously, but when combined with abdominal pain, it raises immediate concern for typhlitis 1 2 3.

Diarrhea and Gastrointestinal Bleeding

Diarrhea is common, occurring in up to half of cases, and may be watery or even bloody. Gastrointestinal bleeding, when present, can be severe and may necessitate additional interventions 1 2 6.

Nausea, Vomiting, and Abdominal Distension

Nausea and vomiting are frequent, reflecting the underlying inflammation and sometimes obstruction of the intestine. Abdominal distension, or visible swelling, can occur as the condition worsens, indicating potential progression towards more severe disease 2 6.

Signs of Severe Disease

Symptoms such as hypotension (low blood pressure), peritonitis (infection of the abdominal cavity), and shock are less common but portend a worse prognosis. Their presence typically signals the need for urgent intervention 2 6.

Types of Typhlitis

While typhlitis is most often discussed in the context of neutropenic enterocolitis, it can manifest in several forms depending on the underlying cause and patient population. Understanding these distinctions is vital for accurate diagnosis and tailored treatment.

Type	Patient Group/Trigger	Key Features	Source(s)
Neutropenic	Chemotherapy, leukemia	Classic typhlitis	1 2 3 6 8
Infectious	Bacterial, viral, fungal	Linked to pathogens	5 8
Non-neutropenic	Rare, e.g., faecolith	Non-chemotherapy	4

Table 2: Types of Typhlitis

Neutropenic Typhlitis

The most well-known and dangerous form of typhlitis occurs in the setting of neutropenia—a profound decrease in white blood cells, typically due to chemotherapy for leukemia or other cancers. This form is characterized by rapid onset and a fulminant course, with significant risk of complications and mortality 1 2 3 6 8.

Infectious Typhlitis

Although chemotherapy-induced neutropenia is the most common risk factor, infectious agents such as bacteria (including those from the gut flora), viruses, and fungi can also play a central role—especially in animal models or in the presence of specific pathogens like Helicobacter hepaticus 5 8. These cases may occur in immunocompromised or, rarely, immunocompetent individuals.

Non-neutropenic Typhlitis

Occasionally, typhlitis may be triggered by factors unrelated to neutropenia. For example, isolated cases have been reported where physical obstruction, such as a faecolith (hardened stool), led to acute inflammation of the cecum, mimicking appendicitis and requiring surgical intervention 4. These cases are rare but highlight the importance of considering typhlitis in the differential diagnosis of right lower quadrant abdominal pain.

Causes of Typhlitis

The development of typhlitis is typically multifactorial, involving a combination of immunosuppression, mucosal injury, and microbial invasion. Understanding these causes can help clinicians identify at-risk patients and initiate early preventative strategies.

Cause	Mechanism/Description	Risk Group	Source(s)
Chemotherapy	Mucosal injury, neutropenia	Cancer patients	1 2 3 6 8
Infections	Bacterial, viral, fungal invasion	Immunocompromised	5 8
Physical Obstruction	Cecal faecolith, other mechanical	Rare, all patients	4
Underlying Disease	Leukemia, hematologic malignancies	High-risk	1 2 3 6 8

Table 3: Causes of Typhlitis

Chemotherapy and Mucosal Injury

The primary driver of typhlitis is chemotherapy-induced damage to the intestinal mucosa. High-dose chemotherapeutic agents, particularly those used in acute leukemia treatment, can severely disrupt the protective lining of the gut. This, combined with profound neutropenia, creates an environment where opportunistic pathogens can invade and cause severe inflammation 1 2 3 6 8.

Infections

Secondary infection by gut bacteria, viruses, or fungi often follows mucosal injury. In neutropenic patients, even normally harmless intestinal flora can become pathogenic, leading to sepsis and rapid clinical deterioration 5 8. Blood cultures in typhlitis patients often grow intestinal organisms, underscoring the infectious component 1.

Physical Obstruction

Although rare, physical causes such as a faecolith (a hard, stone-like mass of stool) can block the cecum and trigger acute inflammation. This form of typhlitis is not associated with neutropenia or chemotherapy but can present similarly 4.

Underlying Disease

Patients with hematologic malignancies, especially acute myeloid leukemia (AML) and acute lymphoblastic leukemia (ALL), are at highest risk. The risk of typhlitis is particularly elevated during phases of intense chemotherapy, such as induction therapy 1 2 3 6 8.

Treatment of Typhlitis

Treating typhlitis is a delicate balance between aggressive medical management and, in some cases, surgical intervention. The approach depends on the severity of the disease, the patient's overall health, and the presence of complications such as perforation or uncontrolled sepsis.

Treatment	Description/Approach	Indication	Source(s)
Medical Management	IV antibiotics, bowel rest, nutrition	First-line for most	1 2 6 8
Surgery	Resection, hemicolectomy, ileostomy	Complications/severe	1 6 7
Supportive Care	Fluids, vasopressors, blood products	As needed	1 6 7 8
Prophylaxis/Prevention	Antibiotics, bowel rest pre-therapy	High-risk patients	5 6

Table 4: Treatment Approaches in Typhlitis

Medical Management

The mainstay of treatment for typhlitis is prompt, broad-spectrum intravenous antibiotic therapy targeting both gram-negative and anaerobic organisms. Bowel rest, typically involving nil per os (NPO) status and nasogastric suction, helps minimize further injury. Total parenteral nutrition (TPN) is often necessary to maintain nutritional status while the bowel heals 1 2 6 8.

• Antibiotic combinations may include agents like ampicillin, metronidazole, and bismuth, among others 5.
• Granulocyte-colony stimulating factor (G-CSF) may be used to hasten recovery from neutropenia 8.

Surgical Intervention

Surgery is reserved for patients who develop complications such as:

• Persistent gastrointestinal bleeding
• Perforation (free air in the abdomen)
• Uncontrolled sepsis despite medical therapy
• Obstruction or abscess formation

When surgery is required, the typical approach is resection of necrotic bowel, often via right hemicolectomy and creation of an ileostomy. The decision to operate is complex, given the high operative risk in immunocompromised patients, but early surgical intervention has led to successful outcomes in select cases 1 6 7.

Supportive Measures

Supportive care includes intravenous fluids, vasopressors for shock, and blood product transfusions for anemia or coagulopathy. These measures are vital for stabilizing critically ill patients 1 6 7 8.

Prevention and Prophylaxis

In high-risk patients, particularly those with a prior history of typhlitis or severe gastrointestinal complaints, prophylactic measures such as bowel rest and TPN at the start of chemotherapy may help reduce risk. Antibiotic prophylaxis has shown benefit in animal models, especially against specific pathogens like Helicobacter hepaticus 5 6.

Conclusion

Typhlitis is a dangerous and rapidly progressive condition, most often affecting immunocompromised patients such as those undergoing chemotherapy for leukemia. Its classic presentation—right lower quadrant abdominal pain, fever, and diarrhea—demands immediate attention. Early recognition, aggressive medical management, and timely surgical intervention when necessary are key to improving outcomes.

Summary Points:

• Typhlitis primarily affects immunocompromised, especially neutropenic, patients undergoing chemotherapy 1 2 3 6 8.
• Symptoms include right lower quadrant abdominal pain, fever, diarrhea, and in severe cases, hypotension and peritonitis 1 2 3 6.
• Types range from classic neutropenic typhlitis to rare forms caused by infection or physical obstruction 1 2 3 4 5 6 8.
• Causes are multifactorial, with chemotherapy-induced mucosal injury and secondary infection being most common 1 2 3 5 6 8.
• Treatment requires prompt antibiotics, bowel rest, supportive care, and sometimes surgery for complications 1 2 6 7 8.
• Prevention and early intervention are crucial in high-risk patients 5 6 8.

Awareness and rapid response are vital—typhlitis remains a serious but potentially manageable complication for the modern patient and care team.