From the Guidelines
Enterocolitis, an inflammation of the small intestine and colon, should be treated with high-dose systemic glucocorticoids as the first line of treatment, with infliximab or vedolizumab considered as second-line immunosuppressants for patients who do not respond to glucocorticoids within 72 hours or have recurrent symptoms during steroid taper. The diagnosis of enterocolitis typically involves excluding infectious causes of diarrhea, such as Clostridioides difficile, and evaluating the severity of the condition using the Common Terminology Criteria for Adverse Events (CTCAE) grading system 1.
Diagnosis
The differential diagnosis for patients with suspected immune checkpoint inhibitor (ICI) enterocolitis is broad, and it is essential to exclude infectious causes of diarrhea before initiating immunosuppressive treatment 1. Stool tests for evidence of inflammation, such as lactoferrin and calprotectin, can be valuable in diagnosing ICI enterocolitis. Endoscopic examination with biopsies is the reference standard for diagnosis, and early endoscopy is correlated with improved outcomes in retrospective analyses 1.
Treatment
The treatment of enterocolitis depends on the underlying cause, but high-dose systemic glucocorticoids are typically used as the first line of treatment. For patients who do not respond to glucocorticoids within 72 hours or have recurrent symptoms during steroid taper, infliximab or vedolizumab may be considered as second-line immunosuppressants 1. The choice between infliximab and vedolizumab should be based on other risk factors, such as the underlying malignancy and comorbidities, risk of infection, and expected duration of treatment.
Management Algorithm
A management algorithm for ICI colitis has been proposed, which includes supportive care, withholding ICI therapy, and considering colonoscopy or flex sigmoidoscopy with biopsies for patients with suspected ICI enterocolitis 1. The algorithm also recommends considering infliximab or vedolizumab for patients who do not respond to oral corticosteroids or have severe colitis.
Key Considerations
It is essential to note that patient symptoms do not correlate with endoscopic findings or predict the response of enterocolitis to treatment 1. Endoscopic findings, such as colonic ulceration, can predict the need for secondary immune suppression. The use of infliximab or vedolizumab should be based on the individual patient's risk factors and the severity of the condition.
Conclusion is not allowed, so the response ends here.
From the Research
Diagnosis of Enterocolitis
- The diagnosis of enterocolitis, particularly necrotizing enterocolitis (NEC), is often based on clinical presentation and radiographic findings, such as pneumatosis intestinalis 2.
- The etiology of NEC remains unknown, but it is believed to involve a combination of factors, including gut maturation, feeding practices, and inflammation 2.
- In cases of immune checkpoint inhibitor-associated enterocolitis, diagnosis is often based on clinical symptoms and endoscopic findings 3.
Treatment of Enterocolitis
- Antibiotic therapy is a cornerstone of treatment for NEC, both medical and surgical presentations 4, 5.
- The most common antibiotic regimens for NEC include ampicillin, gentamicin, and metronidazole, although there is variability in treatment protocols and no single regimen has been proven superior 4.
- For immune checkpoint inhibitor-associated enterocolitis, treatment options include corticosteroids, infliximab, and vedolizumab, although current recommendations are based on low-quality evidence 3.
- In cases of drug-induced enterocolitis, the first-line therapeutic measure is discontinuation of the offending drug, and prevention and treatment options may include protective systems and diagnostic tools 6.
- Surgical intervention may be necessary in advanced cases of NEC, including peritoneal drainage or laparotomy and resection of the affected intestine 2.