What is the treatment approach for enterocolitis?

Treatment of Enterocolitis

The treatment approach for enterocolitis depends critically on the underlying etiology—neutropenic enterocolitis requires immediate broad-spectrum antibiotics with bowel rest, immune checkpoint inhibitor enterocolitis demands systemic corticosteroids, and neonatal necrotizing enterocolitis necessitates bowel rest with parenteral nutrition and antibiotics. 1

Neutropenic Enterocolitis Management

Initial Medical Treatment

• Start broad-spectrum antibiotics immediately covering enteric gram-negative organisms, gram-positive organisms, and anaerobes 1, 2
• Use monotherapy with piperacillin-tazobactam or imipenem-cilastatin, OR combination therapy with cefepime or ceftazidime plus metronidazole 1, 2
• Administer granulocyte colony-stimulating factors (G-CSFs), nasogastric decompression, intravenous fluids, and enforce strict bowel rest 1, 2
• Add antifungal therapy if no response to antibacterial agents occurs, as fungemia is common in this population 2
• Avoid anticholinergic, antidiarrheal, and opioid agents as they aggravate ileus 2

Diagnostic Workup

• Obtain CT scanning as the preferred imaging modality, looking for concentric bowel wall thickening, pericolic fluid collections, or pneumatosis intestinalis 1, 2
• Perform stool cultures and C. difficile testing; consider ova and parasite testing based on risk factors 1
• Recognize that bowel wall thickening >10 mm on imaging is associated with 60% mortality versus 4.2% when ≤10 mm 2

Surgical Indications

• Operate immediately for free intraperitoneal perforation, abscess formation, persistent gastrointestinal bleeding after correcting coagulopathy, or clinical deterioration despite aggressive medical management 1, 2
• Perform resection of all necrotic material, typically by right hemicolectomy 2
• Avoid primary anastomosis in severely immunocompromised patients due to increased anastomotic leak risk 1, 2

Immune Checkpoint Inhibitor (ICI) Enterocolitis Management

Grading-Based Treatment Algorithm

• For grade 1-2 (mild) disease: Consider mesalamine or oral corticosteroids 1
• For grade 3-4 (moderate to severe) disease: Withhold ICI therapy and administer IV corticosteroids at 0.5–2 mg/kg prednisone equivalent daily with 4–6 week taper 1

Second-Line Immunosuppression

• If no improvement within 3 days of IV corticosteroids, escalate to infliximab (5 mg/kg IV) or vedolizumab (300 mg IV) at weeks 0,2, and 6 1
• Test for C. difficile, CMV, and other infectious etiologies before starting immunosuppressive treatment 1
• Approximately one-third of patients fail first-line glucocorticoid treatment and require second-line agents 1
• Colonic ulceration on endoscopy is the only predictive factor for needing secondary immunosuppression, making endoscopic evaluation critical for risk stratification 1

Biologic Selection Strategy

• Choose vedolizumab over infliximab in patients with concurrent ICI hepatitis, as infliximab can induce rare hepatitis 1
• Base selection on patient-specific factors including underlying malignancy, infection risk, and concurrent immune-related adverse events 1

Critical Pitfalls to Avoid

• Do not delay imaging in patients with pain, fever, or bleeding, though diarrhea alone does not warrant abdominal imaging 1
• Do not rely on CTCAE grading alone to predict need for second-line immunosuppression; only colonic ulceration is predictive 1
• Perform early endoscopy as it correlates with improved outcomes 1

Neonatal Necrotizing Enterocolitis Management

Medical Management

• Institute immediate bowel rest, intravenous fluid administration, and total parenteral nutrition 1
• Administer broad-spectrum antibiotics covering enteric organisms 1, 3
• Monitor closely for signs of perforation or clinical deterioration requiring surgical intervention 1

Surgical Intervention

• Perform peritoneal drainage or surgical bowel resection with creation of stomas when pneumoperitoneum or intestinal perforation occurs 1, 3
• Plan for early ileostomy closure to prevent chronic salt-and-water losses, as prolonged ileostomy is associated with severe acidosis, dehydration, feeding difficulties, and recurrent life-threatening episodes 4
• Recognize that mortality approaches 95% unless the entire bowel is involved, which occurs in ~25% of cases with mortality rates of 40%-90% 1

General Infectious Enterocolitis

Initial Approach

• Focus on fluid and electrolyte repletion and symptomatic care 5
• Reserve empiric antibiotic therapy for clinical or epidemiologic features suggesting treatable bacterial origin or high-risk hosts 5
• Use quinolones as the best initial empiric choice when antibiotics are indicated 5
• Detect leukocytes or blood in stool to reinforce the decision for empiric therapy 5