ECCO Topical Review: Inflammatory Bowel Disease-Like Patterns of Drug Colitis with Practical Guidance and a Focus on Immune Checkpoint Inhibitor-Induced Enterocolitis

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Abstract
Background: Drug-induced enterocolitis (DIC) consists of a heterogeneous group of gastrointestinal inflammatory disorders with clinical, endoscopic, and histological features that often overlap with inflammatory bowel disease (IBD). Given the increasing recognition of immune checkpoint inhibitor (ICI)-induced enterocolitis and the lack of standardized management algorithms, the European Crohn’s and Colitis Organisation (ECCO) convened a multidisciplinary panel to review DIC, with a particular focus on ICI-induced disease. Methods: Gastroenterologists, histopathologists, and oncologists systematically reviewed the literature using Medline, PubMed, EMBASE, and Scopus. Evidence was synthesized into ECCO Current Practice Positions addressing diagnostic principles, histopathological patterns, therapeutic strategies, and ICI-specific considerations. Statements were refined and approved through structured consensus. Results: Twenty-three practice positions were agreed upon. DIC may present with diverse histological patterns, including IBD-like/chronic enterocolitis, acute enterocolitis, microscopic colitis, ischemic-type injury, and mixed features, none of which are pathognomonic. Close clinicopathological collaboration is therefore essential. In suspected ICI-induced enterocolitis, assessment should include Common Terminology Criteria for Adverse Events-based grading, stool testing for pathogens, fecal calprotectin, endoscopy with biopsies, and imaging when indicated. Corticosteroids remain first-line therapy, while mild or microscopic disease may respond to budesonide or beclomethasone. Corticosteroid-refractory or corticosteroid-dependent disease should prompt early escalation to infliximab or vedolizumab. Surgery is reserved for refractory or complicated cases. Rechallenge with ICIs may be considered following multidisciplinary evaluation. Conclusion: DIC represents a diagnostically complex spectrum of disorders that require integrated multidisciplinary evaluation. These ECCO Current Practice Positions provide a practical framework for diagnostic work-up and treatment, particularly for ICI-induced enterocolitis.
Funding Information
  • European Crohn’s and Colitis Organisation

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