What is the treatment for enteritis?

Treatment of Enteritis

The primary treatment for enteritis is oral rehydration therapy (ORT) with reduced osmolarity oral rehydration solution (ORS) as the first-line therapy for mild to moderate dehydration in patients with acute diarrhea from any cause. 1

Diagnosis and Assessment

Before initiating treatment, it's essential to assess the severity and cause of enteritis:

• Uncomplicated enteritis: Mild to moderate diarrhea without systemic toxicity or significant dehydration 2
• Complicated enteritis: Fluid depletion, vomiting, fever, sepsis, neutropenia, bleeding, or severe diarrhea 2

Key diagnostic steps:

• Stool examination for blood, leukocytes, and pathogens
• Microbiological testing to identify specific infectious agents
• Assessment of dehydration status

Treatment Algorithm

1. Rehydration Therapy

Mild to Moderate Dehydration:

• First-line: Reduced osmolarity ORS 1
  • Infants/children: 50-100 mL/kg over 3-4 hours
  • Adolescents/adults: 2-4 L

Severe Dehydration:

• Intravenous fluids: Isotonic crystalloid solutions (lactated Ringer's or normal saline) 1
  • Continue until pulse, perfusion, and mental status normalize
  • Then transition to oral rehydration when possible

Replacement of Ongoing Losses:

• Children <10 kg: 60-120 mL ORS for each diarrheal stool/vomiting episode
• Children >10 kg: 120-240 mL ORS for each diarrheal stool/vomiting episode
• Adults: Ad libitum up to ~2 L/day 1

2. Antimicrobial Therapy

Empiric antimicrobial therapy is NOT recommended for most cases of enteritis unless specific indications exist:

Indications for antimicrobial therapy:

• Infants <3 months with suspected bacterial etiology
• Immunocompromised patients with severe illness and bloody diarrhea
• Patients with fever ≥38.5°C, abdominal pain, and bloody diarrhea presumptively due to Shigella
• Recent international travel with high fever and/or signs of sepsis 1

Recommended antimicrobials when indicated:

• Adults: Fluoroquinolone (e.g., ciprofloxacin) or azithromycin based on local susceptibility patterns
• Children: Third-generation cephalosporin (for infants <3 months) or azithromycin 1

3. Symptomatic Treatment

Antidiarrheal agents:

• Loperamide: Can be used for uncomplicated cases
  • Initial dose: 4 mg, then 2 mg after each loose stool (maximum 16 mg/day) 2, 3
  • CAUTION: Avoid in patients with bloody diarrhea, suspected invasive bacterial infection, or neutropenic enterocolitis 1, 2

4. Dietary Management

• Continue oral nutrition with easily digestible, low-residue foods
• Breastfed infants should continue nursing throughout illness 1
• After rehydration, resume normal diet appropriate for age

Special Considerations

Neutropenic Enterocolitis

For patients with neutropenic enterocolitis (a life-threatening condition):

• Hospitalize for close monitoring
• Administer broad-spectrum antibiotics covering gram-negative, gram-positive, and anaerobic organisms
• Consider piperacillin-tazobactam, imipenem-cilastatin, or cefepime plus metronidazole 1, 2
• Avoid antidiarrheal and antimotility agents as they may aggravate ileus 1
• Consider antifungal therapy if no response to antibacterial agents 1

Radiation Enteritis

For patients with radiation enteritis:

• Try enteral nutrition if oral nutrition is inadequate
• Do not delay home parenteral nutrition (HPN) in malnourished patients if oral/enteral nutrition is inadequate 1

Indications for Hospitalization

Hospitalize patients with:

• Severe dehydration or shock
• Altered mental status
• Failure of oral rehydration therapy
• Ileus
• Bloody diarrhea with high fever
• Severe abdominal pain
• Immunocompromised status with significant symptoms 1, 2

Common Pitfalls to Avoid

1. Delayed recognition of complicated enteritis - Early identification of patients requiring hospitalization is crucial 2

2. Inappropriate use of antimotility agents - Avoid in neutropenic enterocolitis, suspected invasive bacterial infection, or bloody diarrhea 1, 2

3. Inadequate fluid resuscitation - Aggressive hydration is essential in complicated cases 2

4. Delayed surgical consultation - Maintain low threshold for surgical evaluation with signs of perforation, ischemia, or uncontrolled sepsis 2

5. Using inappropriate rehydration solutions - Beverages like apple juice, Gatorade, and commercial soft drinks should not be used for rehydration 1

Remember that most cases of infectious enteritis are self-limiting, and the primary goal of treatment is to prevent and treat dehydration while providing symptomatic relief. Antimicrobial therapy should be reserved for specific indications and tailored based on identified pathogens.