Cecal Perforation: Gastrointestinal Menifestation of Acute Lymphoblastic Leukemia

Background: Hematological malignancies present with gastrointestinal manifestations in the form of typhlitis, colitis and bowel perforation. Prompt diagnosis and appropriate treatment of these entities is essential because they are associated with high morbidity and mortality. Case report: We present a case report of a young female patient who was diagnosed with acute lymphoblastic leukemia and while being on induction chemotherapy started having fever, pneumonia, positive blood culture and was started for that on broad spectrum antibiotics after which she developed abdominal pain and loose motion and was found to have clostridial difficile a toxin positive in blood. Surgical consult was taken for non-settling abdominal pain. It was a challenging diagnosis as patient was having loose motion with positive clostridial difficile further more ct scan abdomen done with contrast showed only bowel thickening which was in favor of colitis along with ascites. She was initially managed conservatively and ascitic diagnostic tap also was done which showed serous fluid. However, her persistent abdominal pain which was not settling led her to go another ct scan abdomen after 3 days of initial ct scan and showed specks of free air around cecum based on which she was taken to operation theatre and was found to have big cecal perforation with fecal peritonitis, she ended up having right hemicolectomy and ileo transverse stoma formation. She had prolonged Intensive Care Unit (ICU) stay but eventually recovered fully and was shifted to general ward where after wound healing was taken over by hematology department for continuation of her chemotherapy. Final histopathology of right hemicolectomy specimen showed focal marked mucosal ulcerations/erosions with patchy submucosal neutrophilic abscesses with fibrinosuppurative necrosis, and marked serositis with dense acute (fibrinopurulent) inflammation, all bowel layers mucosa, sub mucosa, muscularis and serosa showed neutrophilic infiltrates, there was no evidence of pseudomembranous colitis, granuloma or malignancy. Conclusion: Patients on chemotherapy for hematological malignancies are neutropenic and are at high risk of bowel ischemia and perforation emanating to there primary disease, immunocompromised status and direct and indirect side effects of chemotherapeutic agents. A high index of suspicion is needed to diagnose these cases accurately and treat accordingly to prevent mortality.