What is the treatment for small bowel enteritis?

Treatment of Small Bowel Enteritis

The treatment of small bowel enteritis should be tailored to the underlying cause, severity of disease, and patient factors, with initial management focusing on fluid resuscitation, nutritional support, and targeted antimicrobial therapy when indicated. 1

Initial Assessment and Management

Diagnostic Approach

• Exclude mechanical obstruction - CT abdomen/pelvis with IV contrast is the gold standard (>90% diagnostic accuracy) 2
• Consider medication effects on gut motility, especially opioids and anticholinergics 1
• Evaluate for signs of peritonitis, perforation, or bowel ischemia 1

Immediate Interventions

1. Fluid and electrolyte replacement

   • IV fluid resuscitation for dehydrated patients
   • Correct electrolyte abnormalities, particularly potassium 2

2. Bowel rest

   • NPO status initially for symptomatic patients
   • Consider nasogastric tube for decompression if significant vomiting 2

Treatment Based on Etiology

Infectious Enteritis

1. Antimicrobial therapy:

   • For bacterial enteritis with systemic symptoms:

     • Piperacillin/tazobactam 4g/0.5g q6h or 16g/2g by continuous infusion 1
     • For beta-lactam allergies: Eravacycline 1 mg/kg q12h or Tigecycline 100 mg LD then 50 mg q12h 1

   • For C. difficile enteritis:

     • Oral vancomycin 125-500 mg every 6 hours 3
     • Alternative: Metronidazole 500 mg orally every 8 hours 3

2. Duration of therapy:

   • 4 days for immunocompetent, non-critically ill patients 1
   • Up to 7 days for immunocompromised or critically ill patients 1

Inflammatory Bowel Disease-Related Enteritis

For small bowel Crohn's disease:

1. First-line treatment:

   • Corticosteroids for acute flares 1
   • Nutritional therapy (elemental diets) as adjunctive therapy 1

2. Maintenance therapy:

   • Azathioprine 1.5–2.5 mg/kg/day or mercaptopurine 0.75–1.5 mg/kg/day 1
   • Methotrexate 15–25 mg IM weekly for those who have responded to IM methotrexate 1
   • Infliximab for refractory disease 1

3. Important adjunct:

   • Smoking cessation is crucial for maintaining remission 1

Chronic Small Intestinal Dysmotility

1. Symptom management:

   • Minimize medications that affect motility (opioids, anticholinergics) 1
   • Consider gradual supervised opioid withdrawal if narcotic bowel syndrome is present 1

2. Nutritional support:

   • Oral supplements/dietary adjustments initially 1
   • If unsuccessful, consider enteral feeding:
     • Gastric feeding if not vomiting 1
     • Jejunal feeding if gastric feeding fails 1
     • Parenteral nutrition if enteral feeding is not tolerated 1

Management of Complications

Small Bowel Obstruction

• Conservative management for partial obstruction without signs of complications 2
• Surgical intervention for:
  • Complete obstruction
  • Signs of strangulation or perforation
  • Failure of conservative management 1, 2

Nutritional Complications

• Monitor for malnutrition, especially with prolonged NPO status 2
• Consider parenteral nutrition if NPO status is prolonged (>5-7 days) 2

Special Considerations

Immunocompromised Patients

• Lower threshold for antimicrobial therapy 1
• Extended duration of treatment (up to 7 days) 1
• Consider broader antimicrobial coverage:
  • Meropenem 1g q6h by extended infusion
  • Doripenem 500 mg q8h by extended infusion
  • Imipenem/cilastatin 500 mg q6h by extended infusion 1

Septic Shock

• Aggressive fluid resuscitation
• Broad-spectrum antibiotics as listed above for immunocompromised patients 1
• Early surgical consultation for source control 1

Common Pitfalls to Avoid

1. Overuse of antimotility agents in infectious enteritis, which may prolong the infection 4

2. Delayed surgical consultation in patients with signs of peritonitis, perforation, or bowel ischemia 1

3. Prolonged empiric antibiotic use without appropriate diagnostic testing 4

4. Failure to recognize medication-induced enteritis, particularly from opioids and anticholinergics 1

5. Inadequate fluid resuscitation, which can worsen outcomes in severe enteritis 5