What is the initial management for a patient with enterocolitis?

Initial Management of Enterocolitis

The initial management of enterocolitis depends critically on the specific type: for neutropenic enterocolitis, immediately initiate broad-spectrum antibiotics covering gram-negative, gram-positive, and anaerobic organisms along with G-CSFs, IV fluids, nasogastric decompression, and bowel rest; for necrotizing enterocolitis in neonates, provide bowel rest, IV fluid resuscitation, broad-spectrum antibiotics, and nasogastric decompression; for severe ulcerative colitis, administer IV corticosteroids (methylprednisolone 60 mg/24h or hydrocortisone 100 mg four times daily) with IV fluids, electrolyte correction, and thromboprophylaxis. 1, 2, 3

Neutropenic Enterocolitis

Immediate Interventions

• Start broad-spectrum antibiotics immediately covering enteric gram-negative organisms, gram-positive organisms, and anaerobes 1, 4
• Recommended regimens include:
  • Monotherapy: piperacillin-tazobactam OR imipenem-cilastatin 1, 4
  • Combination therapy: cefepime or ceftazidime PLUS metronidazole 1, 4
• Add antifungal therapy if no response to antibacterial agents, as fungemia is common 4

Supportive Care

• Administer granulocyte colony-stimulating factors (G-CSFs) 1, 4
• Place nasogastric tube for bowel decompression 1, 4
• Provide IV fluid resuscitation 1, 4
• Maintain strict bowel rest (NPO status) 1, 4

Critical Monitoring

• Obtain CT scanning as the preferred imaging modality to assess bowel wall thickening (>4 mm diagnostic), pericolic fluid collections, or pneumatosis intestinalis 1, 4
• Monitor for surgical indications: free intraperitoneal perforation, abscess formation, persistent GI bleeding after correction of coagulopathy, or clinical deterioration despite aggressive medical management 1, 4

Important Caveats

• Avoid anticholinergic, antidiarrheal, and opioid agents as they may aggravate ileus 4, 5
• Mortality rates are extremely high (30-82%) if treatment is delayed, making early recognition critical 4

Necrotizing Enterocolitis (Neonates)

Immediate Resuscitation

• Initiate aggressive IV fluid resuscitation at rates exceeding ongoing fluid losses to address hemodynamic instability 2
• Place nasogastric tube immediately for bowel decompression 2
• Maintain NPO status during acute phase 2

Antimicrobial Therapy

• Start broad-spectrum IV antibiotics immediately covering gram-negative, gram-positive, and anaerobic organisms 2
• First-line regimen: ampicillin + gentamicin + metronidazole 2
• Substitute vancomycin for ampicillin if MRSA or resistant enterococcal infection suspected 2
• Consider antifungal therapy (fluconazole or amphotericin B) in extremely low birth weight infants or those with risk factors for invasive candidiasis 2

Monitoring and Support

• Perform serial abdominal examinations to detect perforation early 2
• Monitor complete blood count for thrombocytopenia and neutropenia 2
• Provide blood transfusions for significant bleeding or anemia 2
• Arrange intensive care for hemodynamic and metabolic support in severe cases 2

Surgical Considerations

• Urgent surgical intervention indicated for intestinal perforation or clinical deterioration despite maximal medical therapy 2
• Peritoneal drainage may be used as temporizing measure in very low birth weight neonates with perforation 3
• Surgical options include laparotomy with resection of necrotic bowel and creation of ostomies 2
• Avoid primary anastomosis in severely immunocompromised patients due to increased risk of anastomotic leak 2

Severe Ulcerative Colitis

Initial Medical Therapy

• Administer IV corticosteroids: methylprednisolone 60 mg every 24 hours OR hydrocortisone 100 mg four times daily 3
• Higher doses are no more effective; lower doses are less effective 3
• Treatment should be given for a defined period; extending beyond 7-10 days carries no additional benefit 3
• Alternative: IV ciclosporin 2 mg/kg/day monotherapy in patients who should avoid steroids (steroid psychosis, osteoporosis, poorly controlled diabetes) 3

Essential Supportive Measures

• Provide IV fluid and electrolyte replacement with potassium supplementation of at least 60 mmol/day (hypokalaemia or hypomagnesaemia can promote toxic dilatation) 3
• Administer subcutaneous prophylactic low-molecular-weight heparin for thromboprophylaxis 3
• Correct electrolyte abnormalities and anemia as needed 3

Diagnostic Workup

• Perform unprepared flexible sigmoidoscopy with biopsy to confirm diagnosis and exclude CMV infection 3
• Obtain stool cultures and C. difficile toxin assay 3
• If C. difficile detected, administer oral vancomycin and consider fecal microbial transplant; stop immunosuppressive therapy if possible 3

Rescue Therapy Considerations

• Consider second-line medical therapy (ciclosporin, tacrolimus, or infliximab) early (on or around Day 3 of steroid therapy) if inadequate response 3
• Patients remaining on ineffective medical therapy suffer high morbidity from delayed surgery 3
• Joint management by gastroenterologist and colorectal surgeon is essential 3

Critical Avoidances

• Withdraw anticholinergic, anti-diarrhoeal, non-steroidal anti-inflammatory, and opioid drugs 3, 5

Infectious Colitis (General)

Initial Assessment

• Perform stool cultures and C. difficile testing 1
• Consider stool ova and parasite testing based on patient risk factors 1
• Multiplex PCR followed by guided culture on PCR-positive pathogens can confirm active infection 6

Antimicrobial Therapy

• Most forms of infectious colitis are treatable with antimicrobials once pathogen identified 6
• Standard culture methods provide isolates for antibiotic susceptibility testing 6