Abdominal pain raises a broad differential diagnosis because SCT patients, often treated with corticosteroids and having transient neutropenia, may not manifest the pain syndromes characteristic of specific GI diseases.
Crampy, abdominal pain can be a prominent feature of those patients with severe gut GVHD, but usually diarrhea and or nausea and vomiting coexist. GVHD is discussed in more detail above.
SCT patients are at risk for developing both calculous and acalculous cholecystitis. Seventy percent of SCT patients develop gallbladder sludge. Patients transplanted for hema-tologic malignancies may develop calcium bilirubinate stones, many of which are not radiolucent. Transplantation recipients who require TPN and have no oral intake for prolonged periods of time immediately post-transplantation, also are at risk for gallbladder stasis due to the lack of food-stimulated cholecystokinin (CCK) release. Although right upper quadrant or epigastric pain are among the most common complaints, the severity and location of pain in the patient treated with corticosteroids may be atypical. If fever is present, cholecystitis should be more strongly considered in the differential diagnosis regardless of the location of the abdominal pain.
An initial examination by ultrasonography should be performed to assess for the presence of gallstones and a thickened gallbladder wall, suggestive of inflammation. If this is equivocal, biliary scintigraphy should be performed to rule out acute cholecystitis. If the gallbladder fills and CCK fails to elicit gallbladder emptying this suggests chronic cholecystitis. The sensitivity of biliary scintigraphy is preserved as long as hepatic bilirubin metabolism is intact. A total bilirubin > 10 mg/dL makes this diagnostic test less useful. Once acute or chronic cholecystitis is diagnosed, surgical therapy should be considered even in the SCT patient. Because thrombocytopenia frequently coexists, surgery is delayed until platelet counts can be maintained over 100 K/mm3 with or without platelet transfusions. Such patients require triple antibiotic therapy until the cholecys-tectomy can be safely performed. Another option to consider is endoscopic gallbladder stenting, which has been successfully performed in high risk surgical patients with end-stage liver disease awaiting orthotopic liver transplantation (Shrestha et al, 1999).
Neutropenic Enterocolitis (Typhlitis)
Typhlitis is an inflammatory process involving the colon that occurs in the neutropenic patient. It is associated with abdominal pain, diarrhea, and fever. Typhlitis is thought to arise by local penetration of bacteria into the colonic wall and can be treated with antibiotic therapy to cover gut flora. The differential diagnosis includes CMV colitis, acute GVHD, and appendicitis. Involvement is generally limited to the cecum and right colon and can be diagnosed by CT scan showing thickening of the colonic wall with mesen-
teric stranding in this area. Pneumatosis intestinalis may be present and complicated by pneumoperitoneum. Surgical intervention is often required, although case reports exist where affected individuals with isolated pneumatosis intestinalis have been treated conservatively with antibiotic therapy alone.
Diffuse abdominal pain whose severity is out of proportion to the abdominal examination and negative radiologic imaging is likely to be due to disseminated varicella virus. The severity of pain requires opiates for relief in most cases. Some patients have had the misfortune of undergoing exploratory laparotomies. The abdominal pain may predate the appearance of vesicular rash by as long as 2 weeks. Serology is not useful in making this diagnosis. Empiric therapy with acy-clovir may attenuate the appearance of the rash.
Pancreatitis chronic pancreatitis as a result of the conditioning therapy or prolonged steroid use may occur late in the posttransplantation period. Affected individuals may present with abdominal pain and/or steatorrhea. Such patients are managed similarly to standard chronic pancreatitis patients. Therapy includes pancreatic enzymes to improve malabsorption or to reduce chronic pain and endoscopic retrograde cholangiography to alleviate pancreatic duct obstruction.
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