Skip to main content

Main menu

  • Home
  • Content
    • Current issue
    • Past issues
    • Sections
    • Collections
  • Podcasts
  • Author Info
    • Overview for authors
    • Publication fees
    • Forms
    • Editorial policies
    • Submit a manuscript
    • Open access
  • Careers
  • Alerts
    • Email alerts
    • RSS
  • About
    • General information
    • Staff
    • Editorial Board
    • Contact
  • CMAJ JOURNALS
    • CMAJ
    • CMAJ Open
    • JAMC
    • JPN

User menu

Search

  • Advanced search
CJS
  • CMAJ JOURNALS
    • CMAJ
    • CMAJ Open
    • JAMC
    • JPN
CJS

Advanced Search

  • Home
  • Content
    • Current issue
    • Past issues
    • Sections
    • Collections
  • Podcasts
  • Author Info
    • Overview for authors
    • Publication fees
    • Forms
    • Editorial policies
    • Submit a manuscript
    • Open access
  • Careers
  • Alerts
    • Email alerts
    • RSS
  • About
    • General information
    • Staff
    • Editorial Board
    • Contact
  • Subscribe to our alerts
  • RSS feeds
  • Follow CJS on Twitter
Review Article

Typhlitis

David R. Urbach and Ori D. Rotstein
CAN J SURG December 01, 1999 42 (6) 415-419;
David R. Urbach
From the Department of Surgery, The Toronto Hospital and the University of Toronto, Toronto, Ont.
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Ori D. Rotstein
From the Department of Surgery, The Toronto Hospital and the University of Toronto, Toronto, Ont.
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
  • Article
  • Figures & Tables
  • Responses
  • Metrics
  • PDF
Loading

Abstract

Objective: To provide an overview of the pathophysiological features and management of the clinical entity typhlitis.

Data sources and study selection: The data presented are derived from a review of the English-language literature on typhlitis. The majority of papers analysed were small clinical series.

Data extraction and synthesis: Data derived from the literature review were collated. The major finding was that typhlitis comprises a number of different diseases characterized by the presence of right lower quadrant pain, an immunocompromised host and altered function of the mucosal barrier of the right colon.

Conclusions: Typhlitis should be suspected in any immunocompromised patient presenting with right lower quadrant pain with compatible radiographic findings. Most patients can be treated conservatively with intravenously administered fluids and antibiotics, although surgery may be necessary if complications arise.

Typhlitis, a syndrome of enterocolitis occurring in immunosuppressed patients, has been reported increasingly over the last 3 decades. The initial descriptions of this syndrome, which has also been termed “necrotizing enteropathy,” 1 “neutropenic enterocolitis” 2 and “ileocecal syndrome,”3 were reported in children who underwent induction chemotherapy for acute leukemia.4 Subsequently, typhlitis has been observed in adults,5 associated with such conditions as myelodysplastic syndromes,6 multiple myeloma,7 aplastic anemia,8 solid malignant tumours,9 cyclic neutropenia,10 sulfasalazine therapy for rheumatoid arthritis,11 the acquired immunodeficiency syndrome,12 and after solid organ13 and bone marrow14 transplantation.

Epidemiology and pathogenesis

It is difficult to determine accurate prevalence rates for typhlitis. The nonspecific features of this illness and similarities to other acute abdominal syndromes in immunosuppressed patients limit the accuracy of clinical series that lack pathological confirmation of the diagnosis. An autopsy study in children with acute leukemia reported evidence of typhlitis in 24%.15 A frequency of 33% was reported in a cohort of children treated for acute myelogenous leukemia.4

The pathogenesis of typhlitis was originally believed to be a combination of shock, treatment-induced necrosis of intestinal leukemic infiltrates, hemorrhage with subsequent mucosal necrosis and traumatic mucosal erosions.1 A more current perspective is that typhlitis is a syndrome associated with a number of clinical scenarios rather than a specific disease and that it results from a combination of mucosal injury and impaired host defences to intestinal organisms.16

Pathological characteristics

Neutropenic enterocolitis typically involves the terminal ileum and right colon.2–5 Many gross and microscopic alterations have been described, including edema of the mucosa or entire intestinal wall, mucosal ulceration, focal hemorrhage and mucosal or transmural necrosis.1,4,7,15,17 Only rarely are leukemic or acute inflammatory infiltrates identified.17 These changes may be induced by several means. Various chemotherapeutic agents are directly toxic to intestinal mucosa.7 Cytosine arabinoside, a common antileukemic drug, has been shown to denude colonic mucosa through a variety of mechanisms.18 In addition, the disappearance of leukemic infiltrates after therapy may disrupt the architecture and blood supply of the intestinal wall.19 There is evidence that neutropenia itself causes mucosal ulceration.16

The lack of a normal granulocytic reaction to infection7 and reduced blood supply to the distended cecum5 impair the local immune response, which may promote the persistence of microorganisms in the bowel wall. Electron microscopy has demonstrated submucosal macrophages laden with gram-negative organisms.17

Microbiologic features

Various organisms, alone or in combination, have been identified in surgical specimens and peritoneal fluid, including gram-negative rods, gram-positive cocci, enterococci, Clostridium septicum, Candida and cytomegalovirus.4,13,15,16 Clostridium difficile toxin is occasionally detected in the stools.13 Bacteremia, often recurrent, is frequently reported.20

Clinical presentation

The typical presentation mimics acute appendicitis and is characterized by fever, nausea, vomiting, diarrhea, abdominal distension and diffuse pain or right lower quadrant abdominal pain and tenderness.13 Occasionally, the boggy cecum is palpable on examination of the abdomen.5 Symptoms often occur 10 to 14 days after initiation of cytotoxic chemotherapy.2,4,17 Neutropenia (polymorphonuclear cells less than 1.0 × 109/L) is usually observed but is not an invariable finding.21

Radiologic findings

Routine radiologic investigation rarely aids in the diagnosis.13 Abnormalities are nonspecific and may include an ileus or small-bowel obstruction, paucity of gas in the right lower quadrant or a dilated fluid-filled cecum. 15,22 Pneumatosis intestinalis in the area of the cecum has been observed. 4 Barium enema is contraindicated if intestinal perforation is suspected, but water-soluble contrast enema may demonstrate thickening and rigidity of the cecal wall.16 Other imaging modalities are more helpful. Abdominal ultrasonography may show an enlarged cecum with characteristic echogenic thickening of the mucosa,23 with or without fluid collections. Computed tomography reveals thickened bowel and abnormally thickened fascial planes.22

Treatment

There have been no randomized trials on the treatment of typhlitis, and there are advocates for both medical24 and surgical25 intervention. In a collective review of 178 reported cases of selected patients, 97 were treated medically, with a 48% death rate, and 81 were treated surgically, with a 21% death rate.16 Many reports have suggested a poor prognosis for typhlitis. 13,19 In general, the outcomes tend to reflect the course of the underlying disease.13 Conservative management consists of bowel rest, intravenously administered fluids and broad-spectrum antibiotic therapy.24 Cytopenias and coagulopathy should be corrected. Recombinant granulocyte colony-stimulating factor (G-CSF) has been used to hasten recovery.26 Sloas and colleagues13 treated 21 of 24 children without operation, with an 8.3% death rate.

Shamberger and colleagues4 proposed 4 indications for surgery in typhlitis: gastrointestinal bleeding that persists after improvement of neutropenia, thrombocytopenia and coagulopathy; free intra-abdominal perforation; clinical deterioration during medical therapy; and differentiation from other acute abdominal diseases for which surgery is indicated. The standard resectional therapy is right hemicolectomy, with or without primary anastomosis, depending on the condition of the patient.2 Defunctioning the colon with a loop ileostomy has been suggested as an alternative. 27 If laparotomy reveals only edematous bowel without severe inflammation or gangrene, a surgeon may opt for nonextirpative treatment, with the caveat that diffuse mucosal necrosis may lurk beneath otherwise unimpressive serosal inflammation. 16

An algorithm for managing a patient with suspected typhlitis is presented in Fig. 1.

FIG. 1
  • Download figure
  • Open in new tab
  • Download powerpoint
FIG. 1

Recommended approach to the patient with suspected typhlitis. G-CSF = granulocyte colony-stimulating factor.

Directions for further investigation

There are recent developments in the management of gastrointestinal diseases that may have an impact on the diagnosis and treatment of typhlitis. Although many of these modalities have not been evaluated specifically in the setting of neutropenic enterocolitis, they represent evolving areas of clinical research. The effectiveness and limitations of novel strategies in the management of typhlitis can only be established by conducting further clinical trials. We propose the following areas in which further investigation is warranted.

Diagnostic laparoscopy

The ultrasonographic and CT features of typhlitis are nonspecific,22,23 and a clinician may not be able to rule out other surgical diseases solely on the basis of imaging tests. In such cases, diagnostic laparoscopy may be helpful.28 Several studies have reported the utility of diagnostic laparoscopy for the investigation of the acute abdomen. 29,30 Laparoscopy is particularly useful in confirming the presence of appendicitis and is able to rule out this diagnosis in 20% to 40% of patients with atypical presentations.29,30

Although its safety in immunosuppressed or neutropenic patients has not been specifically studied, laparoscopy is a well-tolerated procedure in many other settings.28 This technique should be reserved for patients with an acute abdomen and suspected typhlitis when the diagnosis is in doubt despite appropriate cross-sectional imaging and when an alternative surgical process such as appendicitis cannot be ruled out.

Selective decontamination of the digestive tract

Colonization of the gastrointestinal tract with pathologic bacteria is associated with the development of nosocomial infections and multiple organ failure in critically ill surgical patients. 31 The role of the gut as a potential microbial reservoir has prompted investigation into strategies to prevent pathologic colonization. The technique of selective decontamination of the digestive tract (SDD) involves the administration of oral nonabsorbed antibiotics that preferentially eliminate aerobic gram-negative bacteria and fungi while sparing the gram-positive and anaerobic flora.32 A meta-analysis of 36 trials of SDD demonstrated a significant benefit in reducing the rate of pneumonia but only a marginal improvement in survival when both enteral and parenteral antibiotics were administered.33

A role for SDD has already been proposed for infection prophylaxis in leukemic patients during episodes of neutropenia.34,35 However, it remains speculative whether SDD is effective in reducing the incidence of typhlitis in this population. Further studies evaluating SDD in the setting of leukemia should include typhlitis as an outcome to be considered.

Enteral nutrition

The lack of enteral feeding has been associated with bowel mucosal atrophy and the loss of structural and functional integrity of the gut.36 As well, nutrient intake via the enteral route is beneficial in maintaining systemic immunocompetence.37

Although elimination of oral intake has traditionally been prescribed for patients with typhlitis, a strategy of early enteral nutrition should be explored in those patients who can tolerate it. Many of the pathophysiologic abnormalities observed in typhlitis, such as bowel mucosal injury and persistent infection within the intestinal wall, might be prevented by promoting the continued use of the gastrointestinal tract.

Glutamine

Glutamine, a conditionally essential amino acid, has become the subject of intense interest for its effects on the immune system and gastrointestinal tract.38 Glutamine therapy has beneficial effects on both systemic immunity39 and local mucosal immune function of the intestine.40 Infusions of glutamine can decrease the amount of small-bowel atrophy caused by parenteral nutrition. 41 In addition, animal studies have demonstrated that pathologic increases in intestinal permeability can be prevented by the topical or parenteral administration of glutamine.42,43

The ability of glutamine to maintain gut integrity and promote local and systemic immune function strongly suggests that it should be considered for the treatment of typhlitis.

Colony-stimulating factors

CSFs are molecules that can promote hemopoiesis.44 Two recombinant forms of these molecules are available for clinical use, G-CSF and granulocyte-macrophage CSF. In addition to speeding recovery from episodes of neutropenia occurring during chemotherapy treatment,45 treatment with G-CSF also decreases the incidence of complications such as mucositis.46 The ability to improve the neutropenia and intestinal cytotoxic effects of chemotherapy should improve the course of typhlitis. Treatment of typhlitis with G-CSF has already been reported,26 and formal clinical trials are warranted.

Conclusions

The general surgeon occasionally encounters typhlitis in the assessment of patients with an acute abdomen. The diagnosis is usually suggested by the clinical picture of right lower quadrant pain in a patient with neutropenia and is confirmed by abdominal ultrasonography or CT. Although most patients can be successfully managed with intravenous fluids and antibiotics, those with severe cases of typhlitis may require surgical therapy, especially if complications develop. Newer strategies for the diagnosis and treatment of typhlitis are evolving and will add to the armamentarium of clinicians treating this disease.

  • Accepted November 25, 1996.

References

  1. ↵
    1. Amromin GD,
    2. Solomon RD
    . Necrotizing enteropathy: a complication of treated leukemia or lymphoma patients. JAMA 1962;182:23–9.
    OpenUrlCrossRefPubMed
  2. ↵
    1. Wade DS,
    2. Nava HR,
    3. Douglass HO Jr.
    . Neutropenic enterocolitis. Clinical diagnosis and treatment. Cancer 1992; 69: 17–23.
    OpenUrlCrossRefPubMed
  3. ↵
    1. Sherman NJ,
    2. Wooley MM
    . The ileocecal syndrome in acute childhood leukemia. Arch Surg 1973;107:39–42.
    OpenUrlCrossRefPubMed
  4. ↵
    1. Shamberger RC,
    2. Weinstein HJ,
    3. Delorey MJ,
    4. Levey RH
    . The medical and surgical management of typhlitis in children with acute nonlymphocytic (myelogenous) leukemia. Cancer 1986; 57: 603–9.
    OpenUrlCrossRefPubMed
  5. ↵
    1. Ikard RW
    . Neutropenic typhlitis in adults. Arch Surg 1981;116:943–5.
    OpenUrlCrossRefPubMed
  6. ↵
    1. Sra JS,
    2. Owens MR
    . Typhlitis occurring in a myelodysplastic syndrome. N Y State J Med 1989;89:89–90.
    OpenUrlPubMed
  7. ↵
    1. Alt B,
    2. Glass NR,
    3. Sollinger H
    . Neutropenic enterocolitis in adults: review of the literature and assessment of surgical intervention. Am J Surg 1985; 149:405–8.
    OpenUrlCrossRefPubMed
  8. ↵
    1. Mulholland MW,
    2. Delany JP
    . Neutropenic enterocolitis and aplastic anemia: a new association. Ann Surg 1983; 197:84–90.
    OpenUrlPubMed
  9. ↵
    1. Pestalozzi BC,
    2. Sotos GA,
    3. Choyke PL,
    4. Fisherman JS,
    5. Cowan KH,
    6. O’Shaughnessy JA
    . Typhlitis resulting from treatment with taxol and doxorubicin in patients with metastatic breast cancer. Cancer 1993:71:1797–800.
    OpenUrlCrossRefPubMed
  10. ↵
    1. Geelhoed GW,
    2. Kane MA,
    3. Dale DC,
    4. Wells SA
    . Colon ulceration and perforation in cyclic neutropenia. J Pediatr Surg 1973;8:379–82.
    OpenUrlCrossRefPubMed
  11. ↵
    1. Chakravarty K,
    2. Scott DG,
    3. McCann BG
    . Fatal neutropenic enterocolitis associated with sulphasalazine therapy for rheumatoid arthritis. Br J Rheumatol 1992;31:351–3.
    OpenUrlCrossRefPubMed
  12. ↵
    1. Till M,
    2. Lee N,
    3. Soper WD,
    4. Murphy RL
    . Typhlitis in patients with HIV-1 infection. Ann Intern Med 1992; 116: 998–1000.
    OpenUrlPubMed
  13. ↵
    1. Sloas MM,
    2. Flynn PM,
    3. Kaste SC,
    4. Patrick CC
    . Typhlitis in children with cancer: a 30-year experience. Clin Infect Dis 1993;17:484–90.
    OpenUrlCrossRefPubMed
  14. ↵
    1. Nagler A,
    2. Pavel L,
    3. Naparstek E,
    4. Muggia-Sullam M,
    5. Slavin S
    . Typhlitis occurring in autologous bone-marrow transplantation. Bone Marrow Transplant 1992;9:63–4.
    OpenUrlPubMed
  15. ↵
    1. Katz JA,
    2. Wagner ML,
    3. Gresik MV,
    4. Mahoney DH,
    5. Fernbach DJ
    . Typhlitis. An 18-year experience and postmortem review. Cancer 1990;65:1041–7.
    OpenUrlCrossRefPubMed
  16. ↵
    1. Ettinghausen SE
    . Collagenous colitis, eosinophilic colitis and neutropenic colitis. Surg Clin North Am 1993;73: 993–1016.
    OpenUrlPubMed
  17. ↵
    1. Hiruki T,
    2. Fernandes B,
    3. Ramsay J,
    4. Rother I
    . Acute typhlitis in an immunocompromised host: report of an unusual case and review of the literature. Dig Dis Sci 1992;37:1292–6.
    OpenUrlPubMed
  18. ↵
    1. Slavin RE,
    2. Dias MA,
    3. Saral R
    . Cytosine arabinoside induced gastrointestinal toxic alterations in sequential chemotherapeutic protocols. Cancer 1978; 42:1747–59.
    OpenUrlCrossRefPubMed
  19. ↵
    1. Sherman NJ,
    2. Williams K,
    3. Wooley MM
    . Surgical complications in the patient with leukemia. J Pediatr Surg 1973; 8:235–44.
    OpenUrlPubMed
  20. ↵
    1. Pokorney BH,
    2. Jones JM,
    3. Shaikh BS,
    4. Aber RC
    . Typhlitis: a treatable cause of recurrent septicemia. JAMA 1980; 243:682–3.
    OpenUrlCrossRefPubMed
  21. ↵
    1. Jumper C,
    2. Weems JJ Jr.,
    3. Lettau LA
    . Typhlitis and HIV [letter, comment]. Ann Intern Med 1992;117(8):698. Comment on: Ann Intern Med 1992; 116(12 Pt 1):998–1000.
    OpenUrlPubMed
  22. ↵
    1. Adams GW,
    2. Rauch RF,
    3. Kelvin FM,
    4. Silverman PM,
    5. Korobkin M
    . CT detection of typhlitis. J Comput Assist Tomogr 1985;9:363–5.
    OpenUrlPubMed
  23. ↵
    1. Alexander JE,
    2. Williamson SL,
    3. Siebert JJ,
    4. Goladay ES,
    5. Jimenez JF
    . The ultrasonographic diagnosis of typhlitis (neutropenic enterocolitis). Pediatr Radiol 1988;18:200–4.
    OpenUrlCrossRefPubMed
  24. ↵
    1. Shaked A,
    2. Shinar E,
    3. Freund H
    . Neutropenic typhlitis: a plea for conservatism. Dis Colon Rectum 1983; 26: 351–2.
    OpenUrlCrossRefPubMed
  25. ↵
    1. Varki R,
    2. Armitage JO,
    3. Feagler JR
    . Typhlitis in acute leukemia: successful treatment by early surgical intervention. Cancer 1979;43:695–7.
    OpenUrlCrossRefPubMed
  26. ↵
    1. Hanada T,
    2. Ono I,
    3. Hirano C,
    4. Kurosaki Y
    . Successful treatment of neutropenic enterocolitis with recombinant granulocyte colony stimulating factor in a child with acute lymphocytic leukaemia [letter]. Eur J Pediatr 1990;149:811–2.
    OpenUrlPubMed
  27. ↵
    1. Moir CR,
    2. Scudamore CH,
    3. Benny WB
    . Typhlitis: selective surgical management. Am J Surg 1986;151:563–6.
    OpenUrlCrossRefPubMed
  28. ↵
    1. Soper NJ,
    2. Brunt LM,
    3. Kerbl K
    . Laparocopic general surgery. N Engl J Med 1994;330:409–19.
    OpenUrlCrossRefPubMed
  29. ↵
    1. Sugarbaker PH,
    2. Sanders JH,
    3. Bloom BS,
    4. Wilson RE
    . Preoperative laparoscopy in diagnosis of acute abdominal pain. Lancet 1975;1:442–5.
    OpenUrlPubMed
  30. ↵
    1. Paterson-Brown S,
    2. Eckersley JR,
    3. Sim AJ,
    4. Dudley HA
    . Laparoscopy as an adjunct to decision making in the “acute abdomen”. Br J Surg 1986;73:1022–4.
    OpenUrlCrossRefPubMed
  31. ↵
    1. Marshall JC,
    2. Christou NV,
    3. Meakins JL
    . The gastrointestinal tract: the “undrained abscess” of multiple organ failure. Ann Surg 1993;218:111–9.
    OpenUrlCrossRefPubMed
  32. ↵
    1. Stoutenbeek CH,
    2. van Saene HK,
    3. Miranda DR,
    4. Zandstra DF
    . The effect of selective decontamination of the digestive tract on colonisation rate and infection rate in trauma patients. Intensive Care Med 1984;10:185–92.
    OpenUrlCrossRefPubMed
  33. ↵
    Selective Decontamination of the Digestive Tract Trialists’ Collaborative Group. Meta-analysis of randomised controlled trials of selective decontamination of the digestive tract. BMJ 1993;307:525–32.
    OpenUrlAbstract/FREE Full Text
  34. ↵
    1. Dekker AW,
    2. Rozenberg-Arska M,
    3. Sixma JJ,
    4. Verhoef J
    . Prevention of infection by trimethoprim-sulfamethoxizole plus amphotericin B in patients with acute nonlymphocytic leukaemia. Ann Intern Med 1981;95(5):555–9.
    OpenUrlPubMed
  35. ↵
    1. Dekker AW,
    2. Rozenberg-Arska M,
    3. Verhoef J
    . Infection prophylaxis in acute leukemia: a comparison of ciprofloxacin with trimethoprim-sulphamethoxazole and colistin. Ann Intern Med 1987;106(1):7–11.
    OpenUrlCrossRefPubMed
  36. ↵
    1. Wilmore DW,
    2. Smith RJ,
    3. O’Dwyer ST
    . The gut: a central organ after surgical stress. Surgery 1988;104:917–23.
    OpenUrlPubMed
  37. ↵
    1. Moore FA,
    2. Feliciano DV,
    3. Andrassy RJ,
    4. McArdle AH,
    5. Booth FVM,
    6. Morgenstein-Wagner TB,
    7. et al
    . Early enteral feeding, compared with parenteral, reduces postoperative septic complications: the results of a meta-analysis. Ann Surg 1992;216:172–13.
    OpenUrlCrossRefPubMed
  38. ↵
    1. Hall JC,
    2. Heel K,
    3. McCauley R
    . Glutamine. Br J Surg 1996;83:305–12.
    OpenUrlCrossRefPubMed
  39. ↵
    1. Plumley DA,
    2. Austgen TW,
    3. Salloum RM,
    4. Souba WW
    . Role of the lungs in maintaining amino acid homeostasis. JPEN J Parenter Enteral Nutr 1990; 14:569–73.
    OpenUrlCrossRefPubMed
  40. ↵
    1. Alverdy JC
    . Effects of glutamine-supplemented diets on immunology of the gut. JPEN J Parenter Enteral Nutr 1990;14(Suppl 4):109S–113S.
    OpenUrlCrossRefPubMed
  41. ↵
    1. Platell C,
    2. McCauley R,
    3. McCulloch R,
    4. Hall J
    . The influence of parenteral glutamine and branched-chain amino-acids on total parenteral nutrition-induced atrophy of the gut. JPEN J Parenter Enteral Nutr 1993;17:348–54.
    OpenUrlCrossRefPubMed
  42. ↵
    1. Dugan ME,
    2. McBurney MI
    . Luminal glutamine perfusion alters endotoxin-related changes in ileal permeability of the piglet. JPEN J Parenter Enteral Nutr 1995;19:83–7.
    OpenUrlCrossRefPubMed
  43. ↵
    1. Li J,
    2. Langkamp-Henken B,
    3. Suzuki K,
    4. Stahlgren LH
    . Glutamine prevents parenteral nutrition-induced increases in intestinal permeability. JPEN J Parenter Enteral Nutr 1994;18:303–7.
    OpenUrlCrossRefPubMed
  44. ↵
    1. Steward WP
    . Granulocyte and granulocyte-macrophage colony-stimulating factors. Lancet 1993;342:153–7.
    OpenUrlCrossRefPubMed
  45. ↵
    1. Crawford J,
    2. Ozer H,
    3. Stroller R,
    4. Johnson D,
    5. Lyman G,
    6. Tabbara I,
    7. et al
    . Reduction by granulocyte colony-stimulating factor of fever and neutropenia induced by chemotherapy in patients with small-cell lung cancer. N Engl J Med 1991;325:164–70.
    OpenUrlCrossRefPubMed
  46. ↵
    1. Gabrilove JL,
    2. Jakubowski A,
    3. Scher H,
    4. Sternberg C,
    5. Wong G,
    6. Grous J,
    7. et al
    . Effect of granulocyte colony-stimulating factor on neutropenia and associated morbidity due to transitional cell carcinoma of the urothelium. N Engl J Med 1988;318:1414–22.
    OpenUrlCrossRefPubMed
PreviousNext
Back to top

In this issue

Canadian Journal of Surgery: 42 (6)
CAN J SURG
Vol. 42, Issue 6
1 Dec 1999
  • Table of Contents
  • Table of Contents (PDF)
  • Index by author

Article tools

Respond to this article
Print
Download PDF
Article Alerts
To sign up for email alerts or to access your current email alerts, enter your email address below:
Email Article

Thank you for your interest in spreading the word on CJS.

NOTE: We only request your email address so that the person you are recommending the page to knows that you wanted them to see it, and that it is not junk mail. We do not capture any email address.

Enter multiple addresses on separate lines or separate them with commas.
Typhlitis
(Your Name) has sent you a message from CJS
(Your Name) thought you would like to see the CJS web site.
CAPTCHA
This question is for testing whether or not you are a human visitor and to prevent automated spam submissions.
Citation Tools
Typhlitis
David R. Urbach, Ori D. Rotstein
CAN J SURG Dec 1999, 42 (6) 415-419;

Citation Manager Formats

  • BibTeX
  • Bookends
  • EasyBib
  • EndNote (tagged)
  • EndNote 8 (xml)
  • Medlars
  • Mendeley
  • Papers
  • RefWorks Tagged
  • Ref Manager
  • RIS
  • Zotero
‍ Request Permissions
Share
Typhlitis
David R. Urbach, Ori D. Rotstein
CAN J SURG Dec 1999, 42 (6) 415-419;
Digg logo Reddit logo Twitter logo Facebook logo Google logo Mendeley logo
  • Tweet Widget
  • Facebook Like

Related Articles

  • No related articles found.
  • PubMed
  • Google Scholar

Cited By...

  • No citing articles found.
  • Google Scholar

Similar Articles

Content

  • Current issue
  • Past issues
  • Collections
  • Alerts
  • RSS

Authors & Reviewers

  • Overview for Authors
  • Publication Fees
  • Forms
  • Editorial Policies
  • Submit a manuscript

About

  • General Information
  • Staff
  • Editorial Board
  • Contact Us
  • Advertising
  • Reprints
  • Copyright and Permissions
  • Accessibility
  • CMA Civility Standards
CMAJ Group

Copyright 2023, CMA Impact Inc. or its licensors. All rights reserved. ISSN 2291-0026

All editorial matter in CJS represents the opinions of the authors and not necessarily those of the Canadian Medical Association or its subsidiaries.

To receive any of these resources in an accessible format, please contact us at CMAJ Group, 500-1410 Blair Towers Place, Ottawa ON, K1J 9B9; p: 1-888-855-2555; e: [email protected].

View CMA's Accessibility policy.

Powered by HighWire