What is the treatment for enteritis?

Treatment for Enteritis

The treatment for enteritis should focus on fluid and electrolyte replacement, symptomatic management, and targeted antimicrobial therapy when indicated based on the severity, etiology, and patient factors. 1

Initial Assessment and Management

Fluid and Electrolyte Replacement

• Mild to moderate dehydration: Reduced osmolarity oral rehydration solution (ORS) is the first-line therapy 2
• Severe dehydration: Intravenous fluids (lactated Ringer's or normal saline) should be administered until pulse, perfusion, and mental status normalize 2
• Electrolyte replacement: Potassium supplementation of at least 60 mmol/day is usually necessary to prevent hypokalemia 2

Diagnostic Workup

• Stool studies for infectious pathogens (C. difficile, Salmonella, E. coli, Campylobacter)
• Laboratory tests including complete blood count, electrolyte profile, and inflammatory markers
• Endoscopic evaluation for symptoms grade >1 or persistent symptoms
• Contrast-enhanced CT scan, especially in immunocompromised patients 1

Treatment Algorithm Based on Severity and Etiology

Mild-Moderate Non-Bloody Enteritis

1. Supportive care:

   • Oral rehydration therapy
   • Dietary modifications
   • Symptomatic treatment with loperamide for non-bloody diarrhea 1

2. Antimicrobial therapy:

   • Generally not recommended for most people with acute watery diarrhea without recent international travel 2
   • Exceptions include immunocompromised patients and ill-appearing young infants 2

Moderate-Severe or Bloody Enteritis

1. Empiric antimicrobial therapy should be considered for:

   • Immunocompromised patients with severe illness 2
   • Infants <3 months of age with suspected bacterial etiology
   • Patients with fever, abdominal pain, and bloody diarrhea presumptively due to Shigella
   • Recent international travelers with fever ≥38.5°C or signs of sepsis 2

2. Choice of antimicrobial agent:

   • Adults: Fluoroquinolone (ciprofloxacin) or azithromycin, depending on local susceptibility patterns 2, 3
   • Children: Third-generation cephalosporin for infants <3 months or azithromycin 2
   • For neutropenic enterocolitis: Monotherapy with piperacillin-tazobactam or imipenem-cilastatin, or combination therapy with cefepime/ceftazidime plus metronidazole 1

Specific Etiologies

Neutropenic Enteritis/Typhlitis

• Broad-spectrum antibiotics and bowel rest
• Emergency surgery only for perforation or ischemia
• Damage control approach in severely sick patients 2

Cytomegalovirus Colitis

• Ganciclovir 5 mg/kg bid IV for 2-3 weeks
• Antiviral therapy, broad-spectrum antibiotics, and bowel rest
• Surgery only for toxic megacolon, fulminant colitis, perforation, or ischemia 2, 1

Clostridioides difficile Colitis

• Oral vancomycin for detected C. difficile infection
• Consider fecal microbial transplant
• Resection of the entire colon for fulminant colitis 2

Inflammatory Bowel Disease-Related Enteritis

• IV corticosteroids (hydrocortisone 400 mg/day or methylprednisolone 60 mg/day) for severe disease
• Concomitant IV metronidazole often advisable
• Infliximab for steroid-refractory cases 2

Monitoring and Follow-up

• Daily clinical assessment with vital signs, fluid status, and electrolytes
• Serial abdominal examinations
• Follow-up imaging if clinical deterioration occurs
• Complete blood count, electrolyte profile, and stool evaluation for blood and pathogens 1

Complications and Warning Signs

• Neutropenia increases risk of rapid progression to ischemia, necrosis, and perforation
• CT findings of bowel wall thickening >10 mm indicate higher mortality risk (60%)
• Early surgical consultation for complicated cases
• Consider second-line immunosuppression if no response to steroids within 72 hours 1

Common Pitfalls to Avoid

1. Delayed recognition of severe disease: Monitor for signs of toxic megacolon, perforation, or sepsis
2. Inappropriate use of antimicrobials: Avoid empiric antibiotics for most cases of acute watery diarrhea without specific indications 2
3. Inadequate fluid resuscitation: Aggressive fluid management is critical, especially in severe cases
4. Failure to consider non-infectious causes: Consider IBD and IBS for symptoms lasting 14 or more days 2
5. Overlooking specific pathogens in immunocompromised hosts: More extensive workup may be needed as fever, leukocytosis, and peritonitis may be mild or absent 2

The management of enteritis requires careful assessment of disease severity, appropriate diagnostic workup, and targeted therapy based on the underlying etiology, with fluid and electrolyte replacement being the cornerstone of treatment for all patients.