What is the treatment approach for distal enteritis?

Treatment Approach for Distal Enteritis

The first-line treatment for distal enteritis should include a combination of topical mesalazine 1g daily with oral mesalazine 2-4g daily, as this combination therapy is more effective than either agent alone for achieving remission. 1

Initial Assessment and Management

• Evaluate the extent of inflammation to determine appropriate formulation of topical therapy (suppositories for disease to the recto-sigmoid junction, foam or liquid enemas for more proximal disease) 1
• Assess for proximal constipation, which should be treated with stool bulking agents or laxatives if present 1
• Monitor for dehydration, which should be avoided to minimize risk of thromboembolism 1

First-Line Treatment Options

• Mild to Moderate Disease:

  • Combination therapy with topical mesalazine 1g daily plus oral mesalazine 2-4g daily (or olsalazine 1.5-3g daily or balsalazide 6.75g daily) 1
  • Topical therapy should be selected based on extent of disease (suppositories vs. enemas) 1

• Alternative First-Line Options:

  • Sulphasalazine 2-4g daily can be considered, particularly in patients with reactive arthropathy, though it has higher incidence of side effects compared to newer 5-ASA drugs 1

Second-Line Treatment

• Topical corticosteroids should be reserved as second-line therapy for patients intolerant of topical mesalazine 1
• For patients failing to improve on combination therapy of oral mesalazine with either topical mesalazine or topical corticosteroids, oral prednisolone 40mg daily should be initiated 1
• Prednisolone should be reduced gradually according to severity and patient response, generally over 8 weeks 1

Management of Specific Presentations

• For Patients with Strictures or Stenosis:

  • Consider diet with adapted texture or distal (post-stenosis) enteral nutrition 1
  • Avoid oral intake and consider parenteral nutrition if obstruction is severe 1

• For Patients with Fistulae:

  • For distal (low ileal or colonic) fistulae with low output, enteral nutritional support is usually sufficient 1
  • For proximal fistulae and/or high output, partial or exclusive parenteral nutrition should be provided 1
  • Consider metronidazole 400mg three times daily for simple perianal fistulae 1

Nutritional Support

• Enteral nutrition appears safe and can be recommended as supportive therapy according to standard nutritional practice 1
• Parenteral nutrition should only be used if intestinal failure occurs 1
• In patients with prolonged nutritional deprivation, monitor for and prevent refeeding syndrome, particularly with respect to phosphate and thiamine 1

Maintenance Therapy

• Lifelong maintenance therapy is generally recommended, especially for patients who relapse more than once a year 1
• Discontinuation of medication may be reasonable for patients with distal disease who have been in remission for 2 years and are averse to such medication 1

Common Pitfalls and Caveats

• Avoid delaying treatment with corticosteroids while waiting for stool microbiology results when acute onset disease is present 1
• Remember that proximal constipation can exacerbate distal disease and should be actively treated 1
• Consider subcutaneous heparin in hospitalized patients to reduce the risk of thromboembolism 1
• Recognize that patient preference has greater influence on management of distal disease compared to extensive disease, due to the option of topical or systemic therapy 1