What is the treatment for enteropathy?

Treatment of Enteropathy

Treatment of enteropathy must be directed at the specific underlying etiology, as management varies dramatically depending on the cause—from simple dietary modification to immunosuppression to surgical intervention. 1

Initial Diagnostic Imperative

Before initiating treatment, you must establish the specific type of enteropathy through:

• Thorough medication review to identify drug-induced causes (olmesartan, mycophenolate mofetil, azathioprine), which resolve with discontinuation 1, 2
• Travel history to assess for tropical sprue or parasitic infections 1
• Assessment of immunoglobulin levels (IgG, IgA, IgM) to identify common variable immunodeficiency 1
• Expert pathology review of intestinal biopsies to confirm enteropathy and guide diagnosis 1

Etiology-Specific Treatment Algorithms

Infectious Enteropathies

• Giardiasis: Metronidazole 1
• Tropical sprue: Tetracycline or doxycycline plus folic acid 1
• Whipple disease: Ceftriaxone or penicillin G, followed by TMP-SMX, hydroxychloroquine, or doxycycline 1
• Tuberculosis: Anti-tuberculous therapy 1

Immune-Mediated Enteropathies

• Seronegative celiac disease: Gluten-free diet with dietitian support, with repeat duodenal biopsies at 12 months to confirm histologic improvement 1, 2
• Common variable immunodeficiency (CVID): Budesonide (note: IV immunoglobulin therapy alone is insufficient for gastrointestinal symptoms) 1, 3
• Autoimmune enteropathy: Immunosuppression with steroids, azathioprine, or infliximab 1, 4
• Collagenous sprue: Gluten-free diet with or without immunosuppression (budesonide, prednisone, azathioprine) 1

Inflammatory Conditions

• Crohn's disease: Immunosuppression and biologic agents 1
• Eosinophilic gastroenteritis: Dietary therapy and glucocorticoids 1
• Graft versus host disease: Prednisone or budesonide 1

Other Specific Causes

• Small intestinal bacterial overgrowth (SIBO): Antibiotics 1
• HIV enteropathy: Antiretroviral therapy 1
• Intestinal lymphoma: Hematology consultation for chemotherapy 1

Protein-Losing Enteropathy Specific Management

Dietary Modification

• Diet low in long-chain triglycerides (<5% of total energy intake) and **enriched with medium-chain triglycerides** (>20% of total energy intake) for intestinal lymphangiectasia 2

Cardiac Causes

• Heart transplantation for severe systemic ventricular dysfunction or protein-losing enteropathy in Fontan circulation 2
• Atrial septal fenestration or Fontan conversion for protein-losing enteropathy not amenable to medical therapy 2
• Surgical pericardiectomy for constrictive pericarditis 2

Nutritional Support Strategy for Severe Dysmotility

When enteropathy causes malnutrition, follow this escalation algorithm:

1. Oral supplements and dietary adjustments as first-line 1, 5
2. Gastric feeding via nasogastric tube if oral route unsuccessful and patient not vomiting 1
3. Jejunal feeding via nasojejunal tube initially, then PEGJ or direct jejunostomy if successful 1
4. Parenteral nutrition if jejunal feeding causes intolerable abdominal distension/pain or severe malnutrition persists 1, 5

Critical Management Principles

Multidisciplinary Team Approach

These patients require MDT management including gastroenterologist, GI physiologist, dietitian, pain specialist, psychiatrist/psychologist, and specialist nurses 1, 5

Opioid Management

• If long-term opioid use present, consider narcotic bowel syndrome and initiate gradual supervised opioid withdrawal with pain specialist involvement 1
• Avoid high doses of opioids and cyclizine as they worsen dysmotility 1

Treatment Goals

• Reduce symptoms (pain, vomiting, distension, diarrhea) 1
• Reduce morbidity and mortality 1
• Achieve BMI within normal range 1
• Improve quality of life 1, 5

Follow-Up and Monitoring

• Regular monitoring of serum albumin levels to evaluate treatment efficacy 2
• Repeat endoscopy with biopsies approximately 12 months after treatment initiation to assess histologic response 1, 2
• For seronegative celiac disease, clinical and histologic improvements on gluten-free diet are required to confirm diagnosis, as serologic markers cannot be used 1

Special Consideration for Idiopathic Cases

For stable patients where no underlying etiology is identified after thorough evaluation, consider watchful waiting with repeat endoscopy after a period without intervention, as 72% of idiopathic seronegative villous atrophy cases resolve spontaneously within 9 months 1