From the Guidelines
Enterocolitis is an inflammation of the small intestine and colon that causes symptoms like abdominal pain, diarrhea, fever, and sometimes bloody stools, and its treatment depends on the cause, with the most recent evidence suggesting that approximately one-third of patients with immune checkpoint inhibitor (ICI) enterocolitis have an inadequate response to first-line glucocorticoid treatment and may require a second-line immunosuppressant, such as infliximab or vedolizumab 1.
Causes and Symptoms
Enterocolitis can be caused by various factors, including infections, immune checkpoint inhibitors, and other medications. Symptoms may include abdominal pain, diarrhea, fever, and bloody stools.
- The differential diagnosis for patients with suspected ICI enterocolitis is broad, and it is essential to exclude infectious causes of diarrhea before initiation of immunosuppressive treatment 1.
- Patient symptoms do not correlate with endoscopic findings or predict the response of enterocolitis to treatment, and endoscopic examination with biopsies is the reference standard for diagnosis of ICI enterocolitis 1.
Treatment
Treatment of enterocolitis depends on the cause and severity of the condition.
- For ICI enterocolitis, the treatment algorithm includes supportive care, withholding ICI therapy, and considering anti-diarrheal agents, oral corticosteroids, and infliximab or vedolizumab for refractory cases 1.
- The optimal choice for second-line immune suppression is currently unknown, but both infliximab and vedolizumab appear to be highly effective using doses and scheduling adapted from the treatment of IBD, with infliximab typically dosed at 5 mg/kg given intravenously and vedolizumab given intravenously at a 300-mg dose 1.
- The decision to choose one biologic therapy over the other should be based on other risk factors, including the underlying malignancy and comorbidities, risk of infection, expected duration of treatment, and other concurrent immune-related adverse events 1.
Management and Prevention
Management of enterocolitis involves a multidisciplinary approach, including gastroenterologists, oncologists, and surgeons.
- Early endoscopy is correlated with improved outcomes in retrospective analyses, although the importance of a tissue diagnosis in ICI enterocolitis management has not been rigorously evaluated 1.
- Patients who do not respond to high-dose glucocorticoids within 72 hours of initiation or do not have a complete response within a week should be considered for second-line immunosuppression, and colonic ulceration is the only currently identified predictive factor associated with the need for secondary immune suppression 1.
From the Research
Definition of Enterocolitis
- Enterocolitis refers to the inflammation of the small and large intestine 2.
- It is a condition that can be caused by various factors, including drug-induced damage, infections, and inflammatory bowel disease [(2,3)].
Causes and Risk Factors
- The causes of enterocolitis can be infectious, non-infectious, or vascular in nature 3.
- Risk factors for enterocolitis include the patient's age, gender, dose of drug, time of exposure, pharmaceutical preparation, drug-drug and drug-food interactions, gut barrier integrity, underlying intestinal conditions, and gut microbiota composition 2.
Diagnosis and Treatment
- Computed tomography (CT) scans are often used as the initial diagnostic test for enterocolitis 3.
- Treatment options for enterocolitis depend on the underlying cause and may include discontinuation of the offending drug, antibiotics, anti-inflammatory medications, and immunosuppressants [(2,3,4,5,6)].
- Aminosalicylates, such as mesalamine, are commonly used to treat ulcerative colitis, a type of enterocolitis [(4,5,6)].
Management and Prevention
- Prevention and management of enterocolitis involve identifying and addressing the underlying cause of the condition 2.
- Maintaining a healthy gut microbiota and avoiding damaging insults to the bowel can help prevent enterocolitis 2.
- Treatment with aminosalicylates, such as mesalamine, can help reduce the risk of colorectal tumors in patients with longstanding ulcerative colitis 4.