From the Guidelines
Enterocolitis, an inflammation of the small intestine and colon, should be diagnosed and treated based on its severity and cause, with the most recent and highest quality study recommending a step-wise approach starting with supportive care and escalating to immunosuppressants like infliximab or vedolizumab for severe or refractory cases, as outlined in the 2021 study published in Gastroenterology 1.
Diagnosis
The diagnosis of enterocolitis involves excluding infectious causes of diarrhea and evaluating the severity of the condition using the Common Terminology Criteria for Adverse Events (CTCAE) grading system, with grade 1 being mild and grade 5 being life-threatening 1. Endoscopic evaluation with biopsies is the reference standard for diagnosis, and early endoscopy is correlated with improved outcomes 1. Stool tests for inflammatory markers like lactoferrin or calprotectin can help stratify patients and select those who require endoscopic evaluation 1.
Treatment
Treatment of enterocolitis depends on its severity and cause. For mild cases, supportive care with fluid and electrolyte replacement may be sufficient. For more severe cases, high-dose systemic glucocorticoids are recommended, with a taper of 4-6 weeks 1. 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 like infliximab or vedolizumab 1. The choice between infliximab and vedolizumab should be based on other risk factors, including the underlying malignancy and comorbidities, risk of infection, and expected duration of treatment 1.
Management Algorithm
A management algorithm for ICI colitis has been proposed, which includes withholding ICI therapy, testing to rule out alternate etiologies, and considering colonoscopy or flex sigmoidoscopy with biopsies for patients with grade 2 or higher diarrhea 1. For patients who do not respond to oral corticosteroids, IV corticosteroids or infliximab/vedolizumab may be considered, with repeat endoscopy after 3 doses of add-on therapy to assess response 1.
Key Considerations
Key considerations in the management of enterocolitis include the need for early diagnosis and treatment, the importance of excluding infectious causes of diarrhea, and the use of immunosuppressants like infliximab or vedolizumab for severe or refractory cases. 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, and expected duration of treatment 1.
From the Research
Diagnosis of Enterocolitis
- The diagnosis of enterocolitis, particularly necrotizing enterocolitis (NEC), is based on clinical manifestations, laboratory tests, and imaging studies 2, 3, 4.
- The clinical presentation of NEC includes abdominal distension, vomiting, and bloody stools, while laboratory tests may show elevated white blood cell count and C-reactive protein 2, 3.
- Imaging studies such as X-rays and ultrasound may show signs of intestinal necrosis and pneumatosis intestinalis 2, 3.
Treatment of Enterocolitis
- The treatment of enterocolitis involves supportive care, antibiotic therapy, and surgical intervention in severe cases 2, 3, 4.
- Antibiotic therapy is a cornerstone of treatment, with ampicillin and gentamicin being commonly used 2, 3.
- The use of additional antibiotics providing anaerobic coverage, such as metronidazole, may be considered in patients with surgical NEC 2, 3.
- Surgical intervention may be necessary in cases of intestinal perforation, necrosis, or stricture formation 3, 4.
Prevention of Enterocolitis
- Prevention of enterocolitis involves avoiding the use of broad-spectrum antibiotics, particularly in neonates 4, 5.
- Maintaining a healthy gut microbiome through the use of probiotics and prebiotics may also help prevent enterocolitis 4, 5.
- Discontinuation of antibiotics at the appropriate time and avoiding the use of drugs that can cause enterocolitis are also important preventive measures 5, 6.
Management of Complications
- Complications of enterocolitis, such as stricture formation and toxic megacolon, require prompt medical and surgical attention 3, 6.
- The management of these complications involves the use of antibiotics, bowel rest, and surgical intervention in severe cases 3, 6.
- Prevention of complications through early recognition and treatment of enterocolitis is crucial to reducing morbidity and mortality 2, 3, 4.