Inpatient Treatment for Enteritis
The primary treatment for enteritis in the inpatient setting includes broad-spectrum antibiotics, bowel rest, and supportive care, with surgical intervention reserved only for cases with perforation or ischemia. 1, 2
Diagnostic Approach
- Clinical presentation: Fever, abdominal pain, diarrhea (may be bloody), and signs of systemic toxicity
- Laboratory tests: Complete blood count, electrolytes, liver function tests, C-reactive protein
- Imaging: Contrast-enhanced CT scan is the most reliable diagnostic tool for inpatient enteritis 1
- Microbiological testing:
- Stool cultures for bacterial pathogens
- Specific testing for Clostridioides difficile and its toxin in patients with diarrhea 1
- Additional microbiologic tests based on clinical presentation and risk factors
Treatment Algorithm
1. Antimicrobial Therapy
- First-line options:
- Monotherapy with anti-pseudomonas β-lactam agent
- Carbapenem
- Piperacillin-tazobactam 2
- For immunocompromised patients:
- Broader coverage may be needed with combination therapy
- Consider adding aminoglycosides at individualized daily doses 1
- Duration: Generally 7-10 days, guided by clinical response 1
2. Supportive Care
- Bowel rest: NPO (nothing by mouth) until clinical improvement
- Fluid resuscitation: Intravenous fluids to correct dehydration and electrolyte abnormalities
- Gastric decompression: Nasogastric tube for significant distension
- Blood product replacement: As needed for anemia or coagulopathy 2
3. Special Considerations by Etiology
Neutropenic Enterocolitis
- Treatment: Non-operative management with broad-spectrum antibiotics and bowel rest
- Monitoring: Close observation for clinical deterioration, serial imaging if high-risk features present
- Surgical indications: Signs of perforation, ischemia, continued bleeding, free air, or uncontrolled sepsis 2
- Procedure: Right colectomy with ileostomy when surgery is needed 1, 2
Cytomegalovirus Colitis
- Treatment: Antiviral therapy, broad-spectrum antibiotics, and bowel rest
- Surgical indications: Toxic megacolon, fulminant colitis, perforation, or ischemia 1
Clostridioides difficile Colitis
- Treatment:
- Mild-moderate: Oral vancomycin or fidaxomicin
- Severe: Intravenous metronidazole plus oral vancomycin
- Fulminant: Early surgical consultation 1
- For refractory cases: Consider fecal microbiota transplantation 1
Radiation Enteritis
- Approach: Follow same criteria as other causes of intestinal failure
- Nutritional support: Consider home parenteral nutrition if oral/enteral nutrition is inadequate 1
4. Monitoring and Response Assessment
- Daily assessment of clinical status, vital signs, and abdominal examination
- Serial laboratory tests to monitor inflammatory markers and electrolytes
- Follow neutrophil count recovery in neutropenic patients, as it correlates with symptom resolution 2
5. Criteria for Surgical Intervention
- Perforation
- Evidence of intestinal ischemia
- Continued intestinal bleeding despite correction of coagulopathy
- Free intraperitoneal air
- Uncontrolled sepsis despite maximal medical therapy 1, 2
Discharge Planning
- Resolution of fever and significant improvement in abdominal symptoms
- Ability to tolerate oral intake
- For patients requiring continued antibiotics, consider oral step-down therapy:
Pitfalls and Caveats
- Immunocompromised patients may present with atypical or minimal symptoms despite severe disease 1
- Clinical signs may not reliably reflect disease severity in immunocompromised patients 1
- Avoid unnecessary surgery in neutropenic enteritis as it can worsen outcomes 2
- Early addition of infliximab or vedolizumab (within 10 days) for immune checkpoint inhibitor-induced colitis can reduce symptom duration 1
- Do not delay parenteral nutrition in malnourished radiation enteritis patients if oral/enteral nutrition is inadequate 1