What is the treatment for acute enterocolitis?

Treatment of Acute Enterocolitis

The treatment of acute enterocolitis depends critically on the underlying etiology and patient population, but generally requires immediate supportive care with intravenous fluids, bowel rest, broad-spectrum antibiotics, and avoidance of antiperistaltic agents, with surgical consultation for complications.

Initial Assessment and Risk Stratification

The clinical context determines management approach:

• Neutropenic/chemotherapy-induced enterocolitis carries high mortality risk due to rapid progression to ischemia, necrosis, hemorrhage, perforation and multisystem organ failure 1
• Bacterial enterocolitis presents with inflammatory-type diarrhea characterized by bloody, purulent, and mucoid stool with fever, tenesmus, and severe abdominal pain 2
• Neonatal necrotizing enterocolitis (NEC) typically presents with apnea, bradycardia, abdominal distension, bloody stools, and bilious emesis 3
• Food protein-induced enterocolitis syndrome (FPIES) manifests as delayed repetitive vomiting that may progress to dehydration, hypotension, and shock 1, 4

Immediate Management - All Types

Supportive Care Foundation

• Bowel rest with nothing by mouth (NPO) status is essential 1, 3, 5
• Nasogastric decompression should be initiated immediately 1, 3, 5
• Intravenous fluid resuscitation to address hemodynamic instability and dehydration 1, 3, 5
• Frequent clinical reassessment with daily review of hemodynamic status, abdominal examination, stool charts, and laboratory parameters 1

Critical Contraindications

Avoid anticholinergic, antidiarrheal, and opioid agents as they may precipitate colonic dilatation, aggravate ileus, and mask clinical deterioration 1, 3, 5, 6. Loperamide is specifically contraindicated in bacterial enterocolitis caused by invasive organisms including Salmonella, Shigella, and Campylobacter, as well as in pseudomembranous colitis 6.

Antibiotic Therapy

Neutropenic/Typhlitis Enterocolitis

• Broad-spectrum antibiotics are mandatory and should not be delayed 1
• Empirical coverage must address bacterial invasion through compromised bowel wall 1

Neonatal NEC

First-line regimens 3:

• Ampicillin + gentamicin + metronidazole, OR
• Ampicillin + cefotaxime + metronidazole, OR
• Meropenem monotherapy

Modifications 3:

• Substitute vancomycin for ampicillin if MRSA or ampicillin-resistant enterococcal infection suspected
• Add fluconazole or amphotericin B for suspected fungal infection

Postoperative Enterocolitis

• Piperacillin-tazobactam, imipenem-cilastatin, or combination therapy with cefepime or ceftazidime plus metronidazole 5
• Add vancomycin for suspected MRSA or resistant enterococcal infections 5

Diagnostic Workup

Essential investigations include 1, 3, 5:

• Daily monitoring: Complete blood count, electrolytes/urea/creatinine, CRP, albumin
• Stool evaluation: C. difficile toxin testing, blood, enteric pathogens
• Serial abdominal X-rays to detect complications
• Cross-sectional imaging (CT/MRI) to assess bowel wall thickening, dilation, perforation, or abscess formation 1

Colonoscopy is contraindicated in neutropenic enterocolitis due to very high perforation risk 1.

Surgical Consultation and Intervention

Indications for Surgery

Immediate surgical consultation is required for 1, 3, 5:

• Evidence of bowel perforation (free intraperitoneal air)
• Persistent gastrointestinal bleeding despite medical management
• Clinical deterioration despite maximal medical therapy
• Abscess formation on imaging
• Failure to improve with conservative management

Surgical Approach

• Resection of all necrotic bowel with creation of ostomies or primary anastomosis 3, 5
• Peritoneal drainage as temporizing measure in very low birth weight neonates 3
• Obtain intraoperative Gram stains and cultures to guide antimicrobial therapy 3, 5

Special Population Considerations

Neutropenic Patients

• When inflammation is limited to cecum and terminal ileum, most patients can be managed conservatively 1
• Granulocyte colony-stimulating factors to normalize neutrophil counts 1, 5
• Repeated imaging needed to exclude abscess or perforation 1
• Early surgical consultation is critical as failure to remove necrotic bowel is often fatal 3

Pediatric Patients

• Oral rehydration therapy (ORT) is first-line for mild-moderate dehydration 7
• For FPIES emergencies: ondansetron and corticosteroids based on severity 1, 4
• Intravenous fluid bolus of 10-20 mL/kg for symptomatic FPIES 1
• Observation period: 1-2 hours for immediate reactions, 4 hours for FPIES 1

Immunosuppressed/Cancer Patients

• Multidisciplinary team approach with gastroenterologist, colorectal surgeon, dietitian, pharmacist on specialized GI ward 1
• VTE prophylaxis with subcutaneous/low molecular weight heparin and compression stockings unless contraindicated 1
• Screen for CMV infection - consider empirical ganciclovir in sick patients with relevant symptoms 1
• Multiple pathogens may be responsible; repeated endoscopic reassessments may be needed 1

Nutritional Management

• Trained dietitian assessment of nutritional status 1
• Enteral feeding preferred over parenteral nutrition when tolerated 1
• No role for routine fasting or total parenteral nutrition 1
• Parenteral nutrition indicated only when enteral route unavailable 1, 3

Monitoring Treatment Response

Track the following parameters 1, 5:

• Decreased abdominal distention
• Resolution of bloody stools
• Improved hemodynamic parameters
• Normalization of laboratory values (thrombocytopenia, neutropenia, metabolic acidosis)

Common Pitfalls to Avoid

• Do not delay antibiotics pending infectious workup in neutropenic or severe cases 1
• Do not use antiperistaltic agents - they increase risk of toxic megacolon and perforation 1, 3, 6
• Do not delay surgical consultation when perforation or clinical deterioration occurs 1, 3
• Do not perform colonoscopy in neutropenic enterocolitis 1
• Rectal bleeding is not a contraindication to VTE prophylaxis 1