What is the appropriate treatment for enteritis?

Treatment of Enteritis

The treatment of enteritis depends critically on the underlying etiology and severity: for sexually transmitted enteritis (from oral-anal contact), supportive care with oral rehydration is primary; for bacterial gastroenteritis, oral rehydration solution is first-line with antimicrobials reserved for specific indications; and for inflammatory bowel disease-related enteritis, multidisciplinary management with IV fluids, thromboprophylaxis, and selective antibiotics for superinfection is essential. 1, 2, 1

Sexually Transmitted Enteritis

Clinical Context

• Enteritis from sexual transmission typically results from oral-anal contact and presents with diarrhea and abdominal cramping without signs of proctitis or proctocolitis 1
• In otherwise healthy persons, Giardia lamblia is most frequently implicated 1
• Among HIV-infected persons, additional pathogens including CMV, Mycobacterium avium-intracellulare, Salmonella, Campylobacter, Shigella, Cryptosporidium, and Microsporidium should be considered 1

Management Approach

• Supportive care with oral rehydration is the cornerstone of treatment 1, 2
• Diagnostic evaluation should include appropriate stool examination and culture to identify the specific pathogen 1
• Antimicrobial therapy should be pathogen-directed once identified 1

Bacterial Gastroenteritis/Enteritis

Primary Treatment: Rehydration

Oral rehydration solution (ORS) is the definitive first-line therapy for mild to moderate dehydration and should be initiated immediately 2

ORS Dosing Specifics

• Mild to moderate dehydration: Administer 50-100 mL/kg over 3-4 hours in infants/children, or 2-4 L in adolescents/adults 2
• Children <10 kg: Give 60-120 mL ORS after each diarrheal stool or vomiting episode (maximum ~500 mL/day) 2
• Children >10 kg: Give 120-240 mL ORS after each diarrheal stool or vomiting episode (maximum ~1 L/day) 2
• Adolescents/adults: Provide ad libitum ORS, up to ~2 L/day 2

Severe Dehydration

• For severe dehydration, shock, altered mental status, or ileus: Administer isotonic IV fluids (lactated Ringer's or normal saline) at 20 mL/kg boluses until pulse, perfusion, and mental status normalize 2
• Nasogastric ORS administration may be considered for moderate dehydration when oral intake is not tolerated 2

Antimicrobial Therapy: Selective Use Only

Empiric antimicrobials are NOT recommended for most bacterial gastroenteritis cases 2

Specific Indications for Antimicrobials

Antibiotics should be considered ONLY in these situations:

• Infants <3 months with suspected bacterial etiology 2
• Immunocompromised patients with severe illness and bloody diarrhea 2
• Patients with fever, abdominal pain, bloody diarrhea, and bacillary dysentery 2
• Documented specific pathogens requiring treatment 2

Antimicrobial Selection When Indicated

• Adults: Fluoroquinolones (ciprofloxacin) or azithromycin, guided by local susceptibility patterns and travel history 2
• Children: Third-generation cephalosporin or azithromycin 2
• Pathogen-specific therapy:
  • Campylobacter: Azithromycin 2
  • Shigella: Ciprofloxacin or another fluoroquinolone 2
  • Salmonella: Ciprofloxacin, TMP-SMX, or amoxicillin 2

Critical Pitfall

NEVER give antibiotics for STEC O157 infections—they increase the risk of hemolytic uremic syndrome 2

Symptomatic Management

Antimotility Agents

• Loperamide is CONTRAINDICATED in children <18 years 2
• Adults with watery diarrhea: Initial dose 4 mg orally, then 2 mg after each loose stool (maximum 16 mg/day) 2, 1
• Avoid loperamide in: Inflammatory diarrhea, bloody diarrhea, or fever 2

Antiemetics

• Ondansetron may be given to children >4 years and adolescents with vomiting to facilitate oral rehydration 2

Adjunctive Therapies

• Probiotics may reduce symptom severity and duration in immunocompetent patients 2
• Zinc supplementation reduces diarrhea duration in children 6 months to 5 years in high zinc deficiency areas or malnourished children 2

Nutritional Management

• Resume age-appropriate diet immediately after rehydration is completed—solid food does not delay recovery 2
• Small, light meals guided by appetite are appropriate once rehydrated 2
• Avoid fatty, heavy, spicy foods, caffeine, and lactose-containing foods if diarrhea is prolonged 2

Inflammatory Bowel Disease-Related Enteritis

Initial Management

All IBD patients presenting with acute abdomen require multidisciplinary management involving gastroenterology and acute care surgery 1

Immediate Interventions

• Adequate volume of IV fluids 1
• Low molecular weight heparin for thromboprophylaxis 1
• Correct electrolyte abnormalities and anemia 1

Antibiotic Use in IBD Enteritis

Antibiotics should NOT be routinely administered—only for superinfection or intra-abdominal abscess 1

When Antibiotics Are Indicated

• For superinfection or abscesses: Prompt antimicrobial therapy against Gram-negative aerobic/facultative bacilli, Gram-positive streptococci, and obligate anaerobic bacilli 1
• Recommended regimens: Fluoroquinolones or third-generation cephalosporin PLUS metronidazole 1
• Duration depends on clinical features and laboratory results (e.g., serum CRP level) 1

Abscess Management

• Abscesses >3 cm: Percutaneous drainage with antibiotics is first-line treatment 1
• Abscesses <3 cm: May be treated with IV antibiotics alone, though recurrence risk is higher, especially with enteric fistula 1
• Clinical improvement should occur within 3-5 days; if not, re-evaluate and consider repositioning drain or surgery 1

Disease-Specific Medical Therapy

Ulcerative Colitis

• Severe active UC in hemodynamically stable patients: IV corticosteroids 1
• Assess response by day 3 1
• Non-responders: Consider medical rescue therapy with infliximab plus thiopurine, or ciclosporin in multidisciplinary approach 1

Crohn's Disease

• Infliximab should be considered for penetrating ileocecal Crohn's disease requiring anti-inflammatory therapy, following adequate resolution of intra-abdominal abscesses 1
• For complex perianal fistulizing disease: Infliximab or adalimumab as first-line therapy combined with azathioprine, following adequate surgical drainage if indicated 1
• Combination of ciprofloxacin and anti-TNF improves short-term outcomes 1

Nutritional Support

• Preoperative nutritional support is mandatory in severely undernourished patients 1
• Total parenteral nutrition reserved for patients unable to tolerate enteral nutrition or when enteral route is contraindicated (shock, intestinal ischemia, high output fistula, severe hemorrhage) 1
• TPN is the mode of choice when emergency surgery is needed for complicated IBD 1

Complicated Diarrhea (Cancer Patients)

Classification and Management

Patients with moderate to severe cramping, nausea/vomiting, diminished performance status, fever, sepsis, neutropenia, bleeding, or dehydration are classified as "complicated" and require hospitalization 1

Intensive Management Protocol

• Hospital admission with IV fluids 1
• Octreotide: Starting dose 100-150 mcg subcutaneously three times daily, or IV 25-50 mcg/hour if severely dehydrated, with dose escalation up to 500 mcg subcutaneously three times daily until controlled 1
• Antibiotics: Fluoroquinolones or metronidazole 1
• Laboratory evaluation: Complete blood count, electrolyte profile, stool work-up for blood, C. difficile, Salmonella, E. coli, Campylobacter, and infectious colitis 1

Neutropenic Enterocolitis

This is a medical emergency with high mortality risk requiring aggressive initial medical management 1

Medical Management

• Broad-spectrum antibiotics covering enteric Gram-negatives, Gram-positives, and anaerobes 1
• Reasonable initial choices: Piperacillin-tazobactam or imipenem-cilastatin monotherapy, OR cefepime/ceftazidime plus metronidazole 1
• G-CSF administration 1
• Nasogastric decompression 1
• IV fluids and bowel rest 1
• Serial abdominal examinations 1
• Consider amphotericin if no response to antibacterials (fungemia is common) 1
• Blood transfusions may be necessary for bloody diarrhea 1

Critical Contraindication

AVOID anticholinergic, antidiarrheal, and opioid agents—they may aggravate ileus 1

Surgical Indications

• Persistent GI bleeding after correcting thrombocytopenia/coagulopathy 1
• Free intraperitoneal perforation 1
• Abscess formation 1
• Clinical deterioration despite aggressive supportive measures 1
• If surgery is performed: Resect all necrotic bowel (usually right hemicolectomy, ileostomy, and mucous fistula); primary anastomosis is NOT recommended due to high leak risk 1

Monitoring and Red Flags

Continue Monitoring Until Resolution

• Hydration status 2
• Electrolyte balance 2
• Nutritional status 2

Seek Immediate Medical Care If

• No improvement within 48 hours 2
• Symptoms worsen or overall condition deteriorates 2
• Severe vomiting preventing oral intake 2
• Persistent fever 2
• Frank blood in stools 2
• Abdominal distension 2

Infection Control

• Hand hygiene after toilet use, diaper changes, before/after food preparation, and before eating 2
• Use gloves, gowns, and proper hand hygiene when caring for patients with diarrhea 2
• Asymptomatic contacts do not need treatment but should follow infection prevention measures 2