Treatment of Enterocolitis
The treatment of enterocolitis depends on the specific type and severity, with neutropenic enterocolitis requiring immediate medical intervention including broad-spectrum antibiotics, bowel rest, IV fluids, and nasogastric decompression to reduce mortality. 1, 2
Types of Enterocolitis and Initial Management
Neutropenic Enterocolitis
- Initial treatment is medical, including broad-spectrum antibiotics, granulocyte colony-stimulating factors (G-CSFs), nasogastric decompression, intravenous fluids, and bowel rest 1, 2
- Antibiotic coverage should include enteric gram-negative organisms, gram-positive organisms, and anaerobes 1
- Recommended antibiotic regimens include:
- Consider antifungal therapy (amphotericin) in cases that don't respond to antibacterial agents, as fungemia is common 1, 2
- Blood transfusions may be necessary for bloody diarrhea 1
- Avoid anticholinergic, antidiarrheal, and opioid agents as they may aggravate ileus 1
Immune Checkpoint Inhibitor (ICI) Enterocolitis
- For mild cases (grade 1-2), consider mesalamine or oral corticosteroids 1, 3
- For moderate to severe cases, withhold ICI therapy and administer IV corticosteroids 1
- If no improvement within 3 days of IV corticosteroids, consider second-line immunosuppression with infliximab or vedolizumab 1
- Test for C. difficile, CMV, and other infectious etiologies before starting immunosuppressive treatment 1
Necrotizing Enterocolitis (in neonates)
- Bowel rest, intravenous fluid administration, total parenteral nutrition, and broad-spectrum antibiotics 1, 4
- In premature infants, peritoneal drainage may be used instead of immediate operation when bowel perforation occurs 1
- Surgical intervention involves bowel resection with creation of stomas or reanastomosis 1
Surgical Intervention Criteria
Surgical intervention is indicated in the following situations:
- Persistent gastrointestinal bleeding after correction of thrombocytopenia and coagulopathy 1, 5
- Evidence of free intraperitoneal perforation 1, 2
- Abscess formation 1
- Clinical deterioration despite aggressive supportive measures 1, 2
- Need to rule out other intra-abdominal processes such as bowel obstruction or acute appendicitis 1
Diagnostic Approach
- For suspected enterocolitis, perform stool cultures and C. difficile testing 1
- Consider stool ova and parasite testing based on patient risk factors 1
- For neutropenic enterocolitis, CT scanning is the preferred imaging modality, showing concentric thickening of the bowel wall, pericolic fluid collections, or pneumatosis intestinalis 2
- For ICI enterocolitis, consider stool inflammatory markers (lactoferrin or calprotectin) to help stratify patients 1
- Endoscopic examination with biopsies is the reference standard for diagnosis of ICI enterocolitis 1
Special Considerations
- In neutropenic enterocolitis, failure to remove necrotic focus in severely immunocompromised patients is often fatal 1
- Primary anastomosis is not generally recommended in severely immunocompromised patients due to increased incidence of anastomotic leak 1, 2
- For ICI enterocolitis, colonic ulceration on endoscopy predicts the need for second-line immunosuppression 1
- In necrotizing enterocolitis, mortality rate is close to 95% unless it involves the entire bowel, which occurs ~25% of the time and is associated with a mortality rate of 40%-90% 1
Prevention Strategies
- For neutropenic enterocolitis, careful monitoring of patients receiving high-dose chemotherapy, particularly cytarabine 2
- For necrotizing enterocolitis, avoidance of preterm birth, use of antenatal steroids, and breast-milk feeding 6
- For ICI enterocolitis, early endoscopy is correlated with improved outcomes 1