What is the diagnosis and treatment for Gastroenterocolitis (inflammation of the stomach and intestines)?

From the Guidelines

Gastroenterocolitis, particularly in the context of immune checkpoint inhibitor (ICI) therapy, requires prompt diagnosis and treatment to prevent severe complications, and according to the most recent evidence 1, the use of high-dose systemic glucocorticoids is the first line of treatment, with infliximab and vedolizumab being reasonable options for glucocorticoid refractory colitis.

Diagnosis and Treatment

The diagnosis of gastroenterocolitis involves excluding infectious causes of diarrhea 1 and considering early stool testing for inflammatory markers. Endoscopic confirmation of the diagnosis and severity of ICI colitis should be considered before initiation of high-dose systemic glucocorticoids 1.

• The treatment typically involves high-dose systemic glucocorticoids, given in doses of 0.5–2 mg/kg prednisone equivalent daily with a taper of 4–6 weeks 1.
• Infliximab and vedolizumab are used as second-line immunosuppressants for patients who do not respond to glucocorticoids, with doses and scheduling adapted from the treatment of IBD 1.
• The choice between infliximab and vedolizumab should be based on other risk factors, including the underlying malignancy and comorbidities, risk of infection, expected duration of treatment, and other concurrent immune-related adverse events 1.

Management and Prevention

• Patients undergoing ICI therapy should undergo baseline evaluation of liver chemistries and pretreatment screening for hepatitis B virus serologies 1.
• Liver chemistries should be repeated before each ICI treatment cycle, with management based on CTCAE grade 1.
• Good hand hygiene and food safety practices can prevent future episodes of gastroenterocolitis.
• Medical attention should be sought if symptoms are severe, persist beyond 5 days, or if there's significant dehydration indicated by decreased urination, extreme thirst, dizziness, or confusion.

Key Considerations

• Colonic ulceration is a predictive factor associated with the need for secondary immune suppression 1.
• CTCAE grading is not predictive of the need for secondary immune suppression 1.
• The use of infliximab in patients with underlying hematologic malignancies should be avoided due to the association with rare lymphomas 1.

From the FDA Drug Label

Gastrointestinal Disorders In general, loperamide hydrochloride should not be used when inhibition of peristalsis is to be avoided due to the possible risk of significant sequelae including ileus, megacolon and toxic megacolon. Treatment of diarrhea with loperamide hydrochloride is only symptomatic. Whenever an underlying etiology can be determined, specific treatment should be given when appropriate (or when indicated).

The use of loperamide hydrochloride for gastroenterocolitis is not recommended when inhibition of peristalsis is to be avoided, due to the risk of significant sequelae. Loperamide hydrochloride is only for symptomatic treatment of diarrhea, and specific treatment for the underlying etiology should be given when appropriate 2.

• Key points:
  • Loperamide hydrochloride should not be used when inhibition of peristalsis is to be avoided
  • Treatment of diarrhea with loperamide hydrochloride is only symptomatic
  • Specific treatment for the underlying etiology should be given when appropriate
  • Loperamide hydrochloride is contraindicated in pediatric patients less than 2 years of age due to the risks of respiratory depression and serious cardiac adverse reactions 2.

From the Research

Gastroenterocolitis Treatment

• Oral rehydration therapy is an effective treatment for dehydration associated with gastroenteritis in children, as shown in a study published in 3.
• The study found that oral rehydration therapy had a higher risk of treatment failure compared to intravenous rehydration therapy, but resulted in shorter hospital stays.
• Another study published in 4 highlights the importance of oral rehydration therapy in treating acute gastroenteritis, and provides guidance on how to select patients and implement therapy.

Oral Rehydration Solutions

• The World Health Organization recommends a formulation of oral rehydration salts for the treatment of acute gastroenteritis, but modifications to the original formula have been proposed to increase tolerability and shorten the duration of diarrhea 5.
• A randomized controlled trial published in 6 compared the efficacy, safety, and palatability of Pedialyte, Gatorade, and a New Oral Rehydration Solution (N-ORS) in adults with viral gastroenteritis, and found that all three solutions were effective in correcting dehydration and improving bowel symptoms.

Management of Gastroenteritis in Children

• The assessment of dehydration in children with gastroenteritis can be done by evaluating abnormal capillary refill, abnormal skin turgor, and abnormal respiratory pattern, as suggested by a study published in 7.
• The study also found that oral or nasogastric rehydration with an oral rehydration solution was equally efficacious as intravenous rehydration, and that ondansetron may be effective in decreasing the rate of vomiting and improving the success rate of oral hydration.
• The majority of children with mild to moderate dehydration can be treated successfully with oral rehydration therapy, as supported by evidence from 3 and 7.