Treatment of Enterocolitis
The treatment of enterocolitis requires a targeted approach based on the specific type and severity of the disease, with initial management including IV fluid resuscitation, broad-spectrum antibiotics, and bowel rest for severe cases. 1
Diagnosis and Initial Evaluation
Before initiating treatment, proper diagnosis is essential:
- Stool studies for infectious pathogens (C. difficile, Salmonella, E. coli, Campylobacter)
- Laboratory tests: complete blood count, electrolytes, inflammatory markers (CRP)
- Endoscopic evaluation for grade >1 symptoms
- Contrast-enhanced CT, especially in immunocompromised patients 1
Treatment Algorithm Based on Severity and Type
Mild to Moderate Disease
- Oral rehydration therapy
- Dietary modifications
- Symptomatic treatment with loperamide for non-bloody diarrhea
- For parasitic infections: TMP-SMZ 160mg/800mg bid or ciprofloxacin 500mg bid for 7 days 1
Severe Disease
- Hospitalization required for grade 3-4 enterocolitis
- Aggressive IV fluid resuscitation
- Broad-spectrum antibiotics:
- Bowel rest with nasogastric decompression
- Specific treatments based on etiology:
For Ulcerative Colitis Enterocolitis
- IV corticosteroids: methylprednisolone 60 mg/24h or hydrocortisone 100 mg four times daily
- For steroid-refractory disease: consider ciclosporin, tacrolimus, or infliximab
- Subcutaneous prophylactic low-molecular-weight heparin to reduce thromboembolism risk 2
For Neutropenic Enterocolitis
- G-CSF administration
- Surgical intervention only for perforation, persistent bleeding, or clinical deterioration 1
For Immune Checkpoint Inhibitor Enterocolitis
- Corticosteroids (1 mg/kg/day prednisone) until symptoms improve to Grade 1
- Infliximab (5 mg/kg IV) or vedolizumab for steroid-refractory cases 1
For CMV Enteritis
- Ganciclovir 5 mg/kg bid IV for 2-3 weeks 1
For Necrotizing Enterocolitis (primarily in premature infants)
- Broad-spectrum antibiotics
- Bowel rest
- Peritoneal drainage or laparotomy with bowel resection when perforation occurs 2, 3
Monitoring and Follow-up
- Daily clinical assessment with vital signs, fluid status, and electrolytes
- Serial abdominal examinations
- Follow-up imaging if clinical deterioration occurs
- Monitor response to steroids within 72 hours for immune-related enterocolitis 1
Special Considerations
Antibiotic Selection
For complicated intra-abdominal infections, appropriate empiric therapy includes:
- Carbapenems (imipenem or meropenem)
- Piperacillin-tazobactam
- Extended-spectrum cephalosporin (cefotaxime, ceftriaxone, ceftazidime, or cefepime) with metronidazole 2
Surgical Management
- Early surgical consultation for complicated cases
- Emergency surgery for perforation, persistent bleeding, or clinical deterioration
- In very low birth weight neonates with necrotizing enterocolitis, peritoneal drainage may be used instead of immediate operation 2
Complications to Monitor
- Neutropenia increases risk of rapid progression to ischemia, necrosis, and perforation
- Progression to toxic megacolon, perforation, and multisystem organ failure
- CT findings of bowel wall thickening >10 mm indicate higher mortality risk (60%) 1
Prevention Strategies for Necrotizing Enterocolitis
- Use of antenatal corticosteroids to enhance fetal maturation if preterm delivery is likely
- Breast milk feeding when possible
- Early initiation of trophic feeds with judicious advancement
- Prophylactic probiotics may play a role in prevention 3