Initial Management of Enteritis and Enterocolitis
The initial management of enteritis and enterocolitis should follow a structured approach based on disease severity, with uncomplicated cases managed with oral hydration, dietary modification, and loperamide, while complicated cases require hospitalization, IV fluids, antibiotics, and possibly more aggressive interventions. 1
Diagnostic Evaluation
Perform stool evaluation including:
- Testing for blood
- Clostridium difficile
- Bacterial pathogens (Salmonella, E. coli, Campylobacter, etc.)
- Other infectious pathogens 1
Laboratory tests:
Consider stool inflammatory markers (lactoferrin or calprotectin) to help stratify patients 1
Liberal use of contrast-enhanced CT scan is recommended, especially in immunocompromised patients, as fever, leukocytosis, and peritonitis may be mild or absent 2
Treatment Based on Severity
Grade 1 (Mild)
- Continue normal activities with close monitoring
- Oral hydration to replace fluid and electrolyte losses
- Dietary modifications (low residue diet)
- Loperamide for symptom control (4 mg initially, then 2 mg after every loose stool, maximum 16 mg/day) 1
- Monitor for dehydration 2
- Close follow-up every 3 days until stabilized 2
Grade 2 (Moderate)
- Consider hospitalization for patients unable to maintain hydration
- IV fluid resuscitation if needed
- Antimicrobial therapy if infectious cause is suspected or confirmed
- Consider gastroenterology consultation 2, 1
- For immune-related colitis: corticosteroids (1 mg/kg/day prednisone) until symptoms improve to Grade 1 2
Grade 3-4 (Severe)
- Hospitalization required
- IV fluid resuscitation and electrolyte replacement
- Bowel rest (NPO status)
- Broad-spectrum antibiotics
- Consider nasogastric decompression
- For immune-related colitis: high-dose corticosteroids (1-2 mg/kg/day prednisone) 2
- Consider early introduction of biologics (infliximab) for steroid-refractory cases 2, 1
Special Considerations
Neutropenic Enterocolitis
- High mortality rate if misdiagnosed or underestimated
- Treatment should be non-operative initially:
- Broad-spectrum antibiotics
- Bowel rest
- Emergency surgery only for perforation or ischemia 2
- CT findings of bowel wall thickening >10 mm indicate higher mortality risk (60%) 2
Infectious Enteritis
- Focus on fluid and electrolyte repletion and symptomatic care
- Empiric antibiotic therapy based on clinical or epidemiologic features suggesting bacterial origin 3
- For febrile dysenteric diarrhea, consider azithromycin 1000mg as a single dose 4
Immune Checkpoint Inhibitor-Induced Enterocolitis
- Grade-based management approach
- For Grade ≥2: hold immunotherapy until recovery to Grade 1
- Corticosteroids as first-line treatment
- Consider biologics (infliximab or vedolizumab) for steroid-refractory cases
- Endoscopic evaluation recommended for Grade ≥2 2, 1
Monitoring and Follow-up
- Daily clinical assessment of symptoms
- Regular monitoring of vital signs, fluid status, and electrolytes
- Serial abdominal examinations
- Follow-up imaging if clinical deterioration occurs 1
Indications for Surgical Intervention
- Persistent gastrointestinal bleeding
- Evidence of free intraperitoneal perforation
- Abscess formation
- Clinical deterioration despite aggressive supportive measures 1
- For neutropenic enterocolitis: damage control approach in severely sick patients with physiological derangement 2
Common Pitfalls and Caveats
- Failure to recognize enterocolitis can lead to perforation, sepsis, and death, especially in high-risk populations (neutropenic patients, immunocompromised) 1
- Symptoms may be mild or absent in immunocompromised patients, requiring higher suspicion and more aggressive diagnostic workup 2
- First-level radiological evaluation with ultrasound and X-ray may not be sufficient for diagnosis in immunocompromised patients 2
- Avoid antimotility agents if infectious colitis is suspected, particularly with bloody diarrhea, until Shiga toxin-producing E. coli is ruled out 4
- Early surgical consultation is recommended for complicated cases 1