Perirectal Abscess Gastrointestinal Infection
7.3 Gastrointestinal
Hemorrhage Severe GI hemorrhage requires immediate medical, and potentially, surgical intervention. Common etiologies include gastritis or esophagi- tis, ulcers, necrotizing pancreatitis, primary GI tumors, infection, and radiation-induced infl am- mation and micro vascular damage i.e., mucosal telangiectasias. Hemorrhagic gastritis of varying severity may occur in almost half of pediatric oncology patients Kaste et al. 1999 . Common etiologies of ulcer formation include peptic ulcer disease, infection, increased intracranial pressure stimulating the vagal nerve and parietal cells Cushing’s ulcer, and steroids. Esophageal bleeding results from progressive esophageal varices associated with portal hypertension or Mallory-Weiss tears with repeated emesis. Tumors precipitate bleeding by vascular infi ltra- tion or abnormal tumor vessel growth direct damage as well as infarctions and lacerations via mass effect indirect damage. Common infec- tious agents that may trigger signifi cant bleeding include fungi such as Candida spp., viral patho- gens including Herpesviridae , C. diffi cile , and the opportunistic protozoan cryptosporidium Kaste et al. 1999 ; Fisher and Rheingold 2011 . Sepsis and disseminated intravascular coagula- tion can exacerbate bleeding. Anti- angiogenic chemotherapeutic agents such as bevacizumab, sunitinib, and sorafenib can cause severe bleeding, poor wound healing, and gastric perfo- ration; such adverse manifestations should prompt immediate discontinuation. Ginkgo biloba, a commonly utilized nutritional supplement for fatigue, depression and memory loss, has been associated with an increased bleeding risk Demshar et al. 2011 . Oncology patients should avoid aspirin and nonsteroidal anti- infl ammatory drugs NSAIDs to reduce bleeding risk. Signs and symptoms of GI hemorrhage vary. Symptoms include pain, hematemesis, melena or hematochezia, and anemia-induced symptoms and signs such as fatigue, headache, dizziness, syncope, dyspnea, pallor, and oliguria. To pre- vent aspiration, the patient’s head of the bed should be at an angle of 30–45° Fisher and Rheingold 2011 . In the patient with signs or symptoms of volume depletion, immediate bolus intravenous isotonic crystalloid fl uids should be initiated and type O − red blood cells considered while awaiting results of blood counts and for preparation of crossmatched packed red blood cells. If thrombocytopenia is suspected, empiric platelet transfusion can also be considered. If hypotension persists despite appropriate fl uids and blood products, vasopressors are indicated. The initial emergent laboratory workup includes: 1 complete blood count CBC to evaluate severity of anemia and thrombocytopenia; 2 coagulation evaluation with prothrombin, partial thromboplastin time and fi brinogen; and 3 type and cross in preparation for blood products. Setting goals and anticipating blood loss will maximize safety. Goals include: 1 correction of anemia, with maintenance of hemoglobin ≥8 g dL; 2 correction of throm bocytopenia, with maintenance of platelets ≥75 × 10 9 L; and 3 correction of any coagulopathy with either fresh frozen plasma or fi brinogen. Complete gut rest may be augmented with histamine blockers or proton pump inhibitors. The necessity of gastric lavage remains unclear. In non-oncology adult patients, the aspirate results determine an individual’s pre- endoscopic risk stratifi cation. A high-risk lesion consists of a bleeding lesion or visible vessel on endoscopy. A bloody versus “coffee-ground” or bilious aspirate is 75 specifi c for an active upper GI bleed Abdulrahman et al. 2004 . Less is known about the utility of gastric lavage in pediatric oncology patients. In children with bright red blood or evidence of brisk bleeding during gastric lavage, management includes prompt endoscopic ligation or sclerotherapy. If the patient has esophageal varices, systemic infu- sion of vasopressin for 24 h may decrease portal circulation enough to halt bleeding without endoscopic intervention. Although endoscopy potentially increases the risk of infection in neutropenic patients, it is the standard method to identify and control both upper and lower GI hemorrhage. If endoscopy fails to identify the origin of the bleed, angiogra- phy or radionuclide scans may help localize the source, assuming that the rate of bleeding exceeds 1 or 0.5 mLmin for these different diagnostic methodologies, respectively. If hemorrhage per- sists or recurs, management includes reevalua- tion and treatment of anemia, thrombocytopenia, and coagulopathies followed by repeat endos- copy or surgical intervention Arul and Spicer 2008 . Surgical intervention should precede endoscopic hemostasis if bleeding is associated with tumor. Figure 7.1 outlines the algorithmic approach to the management of acute GI bleed- ing in pediatric oncology patients.7.4 Pancreatitis
Pancreatitis represents a rare but well-known complication of multiple chemotherapeutic agents, most notably asparaginase, steroids, mer- captopurine and cytarabine Haut 2005 ; Trivedi and Pichumoni 2005 ; Garg et al. 2010 . L-asparaginase and PEG-asparaginase derived from E. coli are well described for inducing acute pancreatitis of all degrees of severity with a reported incidence of 2–18 Knoderer et al. 2007 ; Kearney et al. 2009 . Although suggested in some studies, it is not clear that PEG- asparaginase leads to an increased risk of pancre- atitis as compared to L-asparaginase Silverman et al. 2001 ; Knoderer et al. 2007 . Older patients i.e. 9 years have been noted to have a signifi cantly increased risk of pancreatitis with pancreatitis occurring early after asparagi- nase introduction and typically days after L-asparaginase and weeks after PEG- asparaginase secondary to differences in drug half-life Silverman et al. 2001 ; Knoderer et al. 2007 ; Kearney et al. 2009 . No difference in pan- creatits incidence has been noted with intramus- cular versus intravenous PEG-asparaginase to date Silverman et al. 2010 . In their retrospec - tive review, Knoderer et al. 2007 note that asparaginase-associated pancreatitis was signifi - cantly correlated with concomitant prednisone and daunomycin and signifi cantly less likely with dexamethasone. Reintroduction of aspara- ginase after pancreatitis is controversial. In their review, Kearney et al. 2009 did not show a sig- nifi cant difference in outcome in those patients with and without pancreatitis although their gen- eral practice was to rechallenge patients. Knoderer et al. 2007 reported a 7.7 incidence of pancreatitis with rechallenge as compared to Kearney et al. 2009 who reported a 63 recurrence rate. Clinical diagnosis of asparagi- nase-associated pancreatitis is relatively straight- forward; Kearney et al. 2009 note that all patients presented with abdominal or back pain and the majority had nausea or emesis. Severity of pancreatitis was not noted to correlate with degree of elevation of amylase and lipase Kearney et al. 2009 . Laboratory workup merely supports the clini- cal suspicion of acute pancreatitis. Initial labora- tory tests should include: 1 electrolytes to evaluate for hypocalcemia secondary to its pre- cipitation; 2 renal and liver function tests to monitor for multiorgan failure secondary to cyto- kine release from the infl amed or necrotic pan- creas; 3 triglycerides, inciting agents that when hydrolyzed to free fatty acids lead to free radical damage; and 4 the exocrine enzymes amylase and lipase, which when elevated suggest pancre- atic autodigestion and are the hallmark of diagno- sis Tsuang et al. 2009 . Of note, amylase and lipase may not be signifi cantly elevated. Excessive cytokine release can lead to respiratory distress and therefore arterial blood gas and chest radiog- raphy may be clinically indicated for proper man- agement Arul and Spicer 2008 .Parts
» Supportive Care in Pediatric Oncology irantextbook.ir 93df
» Introduction Supportive Care in Pediatric Oncology irantextbook.ir 93df
» History and Physical Supportive Care in Pediatric Oncology irantextbook.ir 93df
» Defi ning the Risk for Serious
» Initial Laboratory Evaluation Diagnostic Evaluation
» Chest Radiography CXR A supine CXR may identify pleural effusions,
» Computed Tomography CT Radiographic Imaging
» Magnetic Resonance Imaging MRI
» Positron Emission Tomography PET
» Aspergillus Galactomannan GMN Biomarkers for Invasive
» 1,3-β- Biomarkers for Invasive
» Polymerase Chain Reaction PCR
» Viral Studies Diagnostic Evaluation
» Invasive Procedures: Diagnostic Evaluation
» Adult FN Guidelines Empiric Management
» Monotherapy Versus Combination Therapy
» Which Monotherapy to Choose A Cochrane review of antipseudomonal beta-
» Alterations in Initial Empiric FN Antibiotic Management
» Outpatient Management of FN Although there remains a lack of one uniform
» Choice of Empiric Antifungal Therapy
» Duration of Antimicrobial Empiric Management
» Endovascular Sources Empiric Management
» Adjunctive Treatment Empiric Management
» Emergence of Resistant Empiric Management
» Red Blood Cell Administration
» Granulocyte Transfusion Supportive Care in Pediatric Oncology irantextbook.ir 93df
» Hemolytic Transfusion Risks of Blood Product
» Infection and Sepsis Risks of Blood Product
» Allergic Reactions Risks of Blood Product
» Febrile Nonhemolytic Risks of Blood Product
» Transfusion-Related Acute Risks of Blood Product
» Transfusion-Associated Risks of Blood Product
» Iron Overload Risks of Blood Product
» Laboratory Risk Factors Supportive Care in Pediatric Oncology irantextbook.ir 93df
» General Management Supportive Care in Pediatric Oncology irantextbook.ir 93df
» Alkalinization Urinary alkalinization has been a long-standing
» Allopurinol Allopurinol inhibits xanthine oxidase, an enzyme
» Rasburicase Rasburicase, recombinant urate oxidase, converts
» Renal Interventions Supportive Care in Pediatric Oncology irantextbook.ir 93df
» Pathophysiology Superior Vena Cava
» History and Physical Exam SVCSSMS should be suspected in a patient
» Imaging Studies The diagnosis of SVCSSMS is often made on
» Other Studies Tissue is required to make a defi nitive diagnosis
» Treatment Superior Vena Cava
» History and Physical Exam Small pericardial effusions are frequently asymp-
» Imaging and Other Studies The presence of a pericardial effusion can be
» History and Physical Exam Many patients with small pleural effusions are
» Imaging Studies When a pleural effusion is suspected, a chest
» History and Physical Exam Patients with pheochromocytoma typically have
» Laboratory Studies The diagnosis of pheochromocytoma is best made
» Imaging Studies Clinical Presentation
» Pulmonary Leukostasis Supportive Care in Pediatric Oncology irantextbook.ir 93df
» Presentation Spinal Cord Compression
» Differential Diagnosis Spinal Cord Compression
» Imaging MRI of the spine can help narrow the differential
» Surgery Surgery in spinal cord compression can be uti-
» Radiation Therapy The advantages of external beam radiation ther-
» Outcomes Spinal Cord Compression
» Presentation Altered Mental Status
» Initial Management Altered Mental Status
» Metabolic The metabolic causes of AMS or seizure in pedi-
» Chemotherapy-Associated Neurotoxicity Differential Diagnosis
» Posterior Reversible Encephalopathy Syndrome
» Outcomes Altered Mental Status
» Initial Management Increased Intracranial
» Soft Tissue A large meta-analysis of published data suggests
» Cerebrospinal Fluid Hydrocephalus is an excess of CSF within the
» Hemorrhage and Thrombosis Differential Diagnosis
» Idiopathic Intracranial Hypertension Differential Diagnosis
» Presentation of Stroke Cerebrovascular Disease
» Differential Diagnosis Cerebrovascular Disease
» Etiology of Stroke in Pediatric
» Ischemic Stroke After an ischemic stroke is diagnosed, the patient
» Hemorrhagic Stroke Hematomas can expand over several hours from
» Acute Lymphoblastic Supportive Care in Pediatric Oncology irantextbook.ir 93df
» Acute Myelogenous Leukemia Supportive Care in Pediatric Oncology irantextbook.ir 93df
» Acute Promyelocytic Leukemia Supportive Care in Pediatric Oncology irantextbook.ir 93df
» Chronic Myelogenous Supportive Care in Pediatric Oncology irantextbook.ir 93df
» Management of Tumor Supportive Care in Pediatric Oncology irantextbook.ir 93df
» Leukapheresis Supportive Care in Pediatric Oncology irantextbook.ir 93df
» Hyperhydration Other Treatment Modalities
» Hydroxyurea Other Treatment Modalities
» Cranial Irradiation Other Treatment Modalities
» Pseudohyperkalemia Hyperleukocytosis has been noted to cause pseudo-
» Pseudohypoxemia Due to the rapid consumption of oxygen by leu-
» Pseudohypoglycemia Consumption of glucose by excess leukocytes
» Pseudothrombocytosis Leukemic blast lysis can lead to cell fragmenta-
» Transfusion Practice with Other Supportive Care
» Anesthetic Procedures Other Supportive Care
» Neutropenic Enterocolitis Gastrointestinal Infection
» Perirectal Abscess Gastrointestinal Infection
» Gastrointestinal Supportive Care in Pediatric Oncology irantextbook.ir 93df
» Pancreatitis Supportive Care in Pediatric Oncology irantextbook.ir 93df
» Bowel Obstruction Supportive Care in Pediatric Oncology irantextbook.ir 93df
» Abdominal Compartment Supportive Care in Pediatric Oncology irantextbook.ir 93df
» ALL Risk Factors Supportive Care in Pediatric Oncology irantextbook.ir 93df
» Other Malignancies Supportive Care in Pediatric Oncology irantextbook.ir 93df
» Central Venous Catheters Supportive Care in Pediatric Oncology irantextbook.ir 93df
» Diagnosis Supportive Care in Pediatric Oncology irantextbook.ir 93df
» Nociceptive Pain Types of Pain
» Neuropathic Pain Types of Pain
» World Health Organization Pharmacologic Treatment
» Intermittent Opioid Use Pharmacologic Treatment
» Long-Acting Opioids Pharmacologic Treatment
» Breakthrough Dosing Pharmacologic Treatment
» Opioid Rotation Pharmacologic Treatment
» Patient-Controlled Analgesia Pharmacologic Treatment
» Constipation Side Effects of Opioids
» Nausea and Vomiting Nausea and vomiting are rare opioid side effects
» Pruritus Pruritus is a common side effect of opioid use
» Sedation Side Effects of Opioids
» Confusion and Agitation Renal and hepatic function should be checked
» Respiratory Depression When dosed appropriately, opioids rarely result
» Myoclonus Patients receiving very high doses of opioids for
» Urinary Retention Urinary retention can be caused by any opioid but
» Calcium Channel Blockers Neuropathic Pain
» Serotonin and Norepinephrine Neuropathic Pain
» Tricyclic Antidepressants Neuropathic Pain
» Interventional Techniques Supportive Care in Pediatric Oncology irantextbook.ir 93df
» Vincristine-Related Peripheral Oncology-Specifi c Pain
» Osteonecrosis Oncology-Specifi c Pain
» Post-lumbar Puncture Oncology-Specifi c Pain
» Mucositis Pain Oncology-Specifi c Pain
» Pathophysiology of Emesis Chemotherapy-Induced
» Principles of Emesis Control in the Cancer Patient
» Emetogenicity of Chemotherapy Chemotherapy-Induced
» Dopamine Receptor Antagonists Classes of Antiemetics
» Corticosteroids Classes of Antiemetics
» Cannabinoids The plant Cannabis contains more than 60 differ-
» Other Antiemetic Agents Antihistamines
» Alternative Therapies Ginger Classes of Antiemetics
» Management of CINV Management of CINV Table
» Special Considerations Anticipatory Nausea and Vomiting
» Radiation-Induced Nausea Supportive Care in Pediatric Oncology irantextbook.ir 93df
» Initiation The initiation stage occurs immediately following
» Primary Damage Response Pathophysiology of Oral Mucositis
» Signal Amplifi cation Pathophysiology of Oral Mucositis
» Ulceration Ulceration is the phase with the most clinical sig-
» Healing Pathophysiology of Oral Mucositis
» Clinical Course of Oral Mucositis
» Assessment Supportive Care in Pediatric Oncology irantextbook.ir 93df
» Palifermin Prevention and Treatment
» Low-Level Laser Therapy Prevention and Treatment
» Glutamine Prevention and Treatment
» Cryotherapy Prevention and Treatment
» Oral Care Supportive Care in Pediatric Oncology irantextbook.ir 93df
» Oral Infections Supportive Care in Pediatric Oncology irantextbook.ir 93df
» Nutrition Assessment Supportive Care in Pediatric Oncology irantextbook.ir 93df
» Dietary Counseling Nutrition Intervention
» Appetite Stimulants Nutrition Intervention
» Enteral Tube Feeding Nutrition Intervention
» Parenteral Nutrition Nutrition Intervention
» Nutrition and Survivorship Supportive Care in Pediatric Oncology irantextbook.ir 93df
» Management of Neutropenia Hematologic Toxicity
» Management of Thrombocytopenia Hematologic Toxicity
» Management of Anemia Hematologic Toxicity
» Somnolence Syndrome Central Nervous System
» Lhermitte’s Sign Central Nervous System
» Skin Complications Supportive Care in Pediatric Oncology irantextbook.ir 93df
» Oral Mucositis Head and Neck
» Ear Complications Head and Neck
» Laryngeal Complications Head and Neck
» Dysphagia and Esophagitis Gastrointestinal
» Nausea, Vomiting and Anorexia
» Pneumonitis Major Organ Infl ammation
» Pericarditis Major Organ Infl ammation
» Hepatitis Major Organ Infl ammation
» Nephropathy Major Organ Infl ammation
» Cystitis Major Organ Infl ammation
» Risk Stratifi cation Prevention of Bacterial
» Adult Data Antimicrobial Approaches
» Pediatric Data Data regarding the utility of bacterial prophylaxis
» Risks of Prophylaxis Prevention of Bacterial
» Guidelines and Current Usage of Antibacterial Prophylaxis
» Protocols for Line Placement and Care
» Antibiotic and Ethanol Locks
» Chlorhexidine Cleansing Chlorhexidine gluconate CHG is a bactericidal
» Future Directions Prevention of Bacterial
» Risk Stratifi cation Prevention of Fungal
» Approaches to Antifungal Prophylaxis
» Guideline Recommendations for Antifungal Prophylaxis
» Limitations of Current Options for Antifungal Prophylaxis
» Risks of Prophylaxis Prevention of Fungal
» Biomarkers Prevention of Fungal
» Future Directions Prevention of Fungal
» Risk Stratifi cation Prevention of Pneumocystis
» Approaches to PCP Prophylaxis
» Summary of the Recommendations
» Future Directions Prevention of Pneumocystis
» Postexposure Chemoprophylaxis Prevention of Viral Infections
» Suppressive Therapy Prevention of Viral Infections
» Future Directions Prevention of Viral Infections
» Hand Hygiene Infection Control Practices
» Mandatory Vaccination Infection Control Practices
» Hospital Isolation Practices Infection Control Practices
» Visitor Screening Policies Infection Control Practices
» Work Restriction Infection Control Practices
» Cytomegalovirus CMV Status of Transfused Blood
» Treatment of Myelosuppression with
» Prevention of Febrile Neutropenia, Delay
» Treatment of Febrile Neutropenia
» Treatment of Myelosuppression Clinical Usage of Myeloid Growth Factors
» Comparison of Granulocyte Colony-Stimulating Factor
» Optimal Dosing Adult guidelines recommend dosing of 5 mcgkg
» Route of Administration Optimal Administration of Colony-Stimulating Factors
» Optimal Timing Optimal Administration of Colony-Stimulating Factors
» Erythropoietin Supportive Care in Pediatric Oncology irantextbook.ir 93df
» Interleukin-11 Platelet Growth Factors
» Thrombopoietin Receptor Agonists Platelet Growth Factors
» Immune Status Prior Supportive Care in Pediatric Oncology irantextbook.ir 93df
» Immune Status During Supportive Care in Pediatric Oncology irantextbook.ir 93df
» Immune Recovery After Supportive Care in Pediatric Oncology irantextbook.ir 93df
» Immunization Practice Prior Supportive Care in Pediatric Oncology irantextbook.ir 93df
» Diphtheria, Tetanus, and Acellular Pertussis
» Pneumococcal Conjugate Vaccine Recommendations
» Hemophilus Infl uenzae Type b
» Inactivated Infl uenza Vaccine Although in a Cochrane review Goossen et al.
» 2009 H1N1 Pandemic Vaccine Seven studies have reported on effi cacy of the
» Live Attenuated Infl uenza Vaccine
» Meningococcal Conjugate Vaccine Recommendations
» Varicella Zoster Virus Recommendations
» Recommendations Supportive Care in Pediatric Oncology irantextbook.ir 93df
» Treatment of Hypogammaglobulinemia Supportive Care in Pediatric Oncology irantextbook.ir 93df
» Vaccination of Household Contacts
» Peripherally Inserted Central Catheter
» External Tunneled Central Venous Catheter
» Implanted Port Types of Central Venous
» Catheter Insertion Supportive Care in Pediatric Oncology irantextbook.ir 93df
» Exit Site Infection Infection
» Prevention of Infection Infection
» Drug Precipitate or Lipid Residue Occlusion Thrombotic Occlusion
» Evaluation of Catheter- Related Thrombosis
» Treatment of Catheter- Related Thrombosis
» Special Considerations During Anticoagulation Therapy
» Contraindications of Anticoagulant Therapy
» Skin Antisepsis Catheter Maintenance
» Central Venous Catheter Dressings
» Hub Care Catheter Maintenance
» Central Venous Catheter Flushing and Locking
» Chlorhexidine Bathing Chlorhexidine has been shown to be effective in
» Antiseptic Needleless Connectors and Antiseptic
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