What is the treatment approach for enterocolitis?

From the Guidelines

The treatment of enterocolitis, particularly in the context of immune checkpoint inhibitor (ICI) therapy, should prioritize corticosteroids as the first line of treatment for grade 2 or higher events, with infliximab or vedolizumab considered for steroid-refractory cases, as supported by the most recent guidelines 1.

Initial Management

The initial approach to treating enterocolitis involves supportive care and addressing the underlying cause. For ICI-related enterocolitis, it is crucial to exclude infectious causes of diarrhea before initiating treatment 1.

Pharmacological Treatment

• Corticosteroids are the primary treatment for grade 2 or higher ICI-related diarrhea/colitis, with approximately half of individuals experiencing symptom resolution 1.
• Infliximab, a monoclonal anti–tumor necrosis factor alpha (TNF-a) antibody, is used for treating steroid-refractory irAEs, including severe colitis associated with ipilimumab 1.
• Vedolizumab, an integrin antagonist, is indicated for treating gastrointestinal inflammation due to ulcerative colitis and Crohn’s disease and has been used for ICI-induced diarrhea/colitis, offering a more targeted approach to immune suppression in the gut 1.

Diagnostic and Therapeutic Considerations

• Early stool testing for inflammatory markers and endoscopic confirmation of the diagnosis and severity of ICI colitis can help guide treatment decisions 1.
• Abdominal imaging may be considered to exclude serious complications, especially in patients with pain, fever, or bleeding, but is not routine for diarrhea alone 1.
• The introduction of infliximab or vedolizumab within 10 days of colitis onset can reduce symptom duration and improve steroid taper success, with treatment outcomes associated with lower relapse risk 1.

Patient Monitoring and Follow-Up

• Patients undergoing ICI therapy should have baseline and regular evaluations of liver chemistries and hepatitis B virus serologies, with management based on CTCAE grade 1.
• For patients with hepatitis, monitoring and treatment strategies depend on the CTCAE grade, with glucocorticoids and potentially second-line immunomodulators used for higher grades 1.

From the Research

Treatment Approaches for Enterocolitis

• The treatment approach for enterocolitis depends on the underlying cause and severity of the condition 2, 3, 4, 5, 6.
• For pseudomembranous enterocolitis caused by Clostridium difficile infection, treatment involves prompt administration of appropriate antibiotics, withdrawal of suspected predisposing antibiotics, and in rare cases, total colectomy 2.
• In cases of bacterial hemorrhagic enterocolitis, treatment may involve antibiotic therapy, and diagnostic approaches include microscopic study, culture, and identification of specific bacterial toxins 3.
• For necrotizing enterocolitis in preterm neonates, treatment includes bowel rest, careful use of antibiotics, and surgery if necessary 4.
• In cases of neutropenic enterocolitis, a correct baseline evaluation and prompt diagnosis are crucial in making therapeutic decisions, which may involve surgical procedures 5.
• The use of antibiotics in necrotizing enterocolitis varies substantially, and there are no definite outcome differences between different antibiotic treatments 6.

Antibiotic Treatments

• Commonly used antibiotics for enterocolitis include ampicillin, gentamicin, metronidazole, vancomycin, and antipseudomonal agents 3, 6.
• The choice of antibiotic treatment depends on the severity and cause of the enterocolitis, as well as the patient's medical history and other factors 2, 3, 4, 5, 6.

Surgical Interventions

• Surgical interventions may be necessary in cases of necrotizing enterocolitis, neutropenic enterocolitis, or other severe forms of enterocolitis 4, 5.
• The decision to perform surgery depends on the severity of the condition, the presence of complications such as intestinal perforation, and the patient's overall health status 4, 5.