Acute abdominal complications in bone marrow transplant recipients

Bone marrow transplant is currently the treatment of choice for a number of haematological neoplasms. High doses of antiblastic drugs, immunosuppressive agents and acute graft versus host disease before and after bone marrow transplant cause toxic damage to the liver and to the gastrointestinal tract. Related acute abdominal complications often need emergency surgical treatment with a 30-60% mortality rate. In these patients the surgical strategy is complex and hard to schematise. Ninety-one patients undergoing bone marrow transplantation showed acute abdominal symptoms requiring thorough surgical monitoring: 51 had ileocolitis, 17 pancreatitis, 9 cholangitis, 6 cholecystitis, 6 appendicitis, and 2 gastric perforation. Nine patients needed an emergency operation (2 gastroduodenal resections, 1 ileal resection, 2 right hemicolectomies, 2 total colectomies, 1 cholecystectomy and one appendectomy. The operative mortality was 22.2%. Positive blood cultures were quite frequent (63.7%). Moderate granulocytopenia was observed (neutrophils: 500 x mm3) in about 40% of cases, and severe granuloctopenia in only one patient (neutrophils: 100 x mm3) with ileotyphlitis. Moderate thrombocytopenia (PLTS < 50,000 x mm3) was observed in 43.9% of cases while in three cases (all submitted to surgical treatment) the platelet count was < 5,000 x mm3. The recent increase in bone marrow transplants has led to a progressive rise in the number of patients with acute abdominal complications. When deciding the surgical strategy in treating acute abdominal complications the surgeon must consider that surgical intervention is indicated only after unsuccessful medical treatment and that the intestinal segment involved must always be removed as far as possible; severe neutropenia, thrombocytopenia (< 10,000 x mm3) and positive blood cultures, especially for CMV, are unfavourable prognostic factors.