Should patients with an active Crohn's (Crohn's disease) flare be kept NPO (nothing by mouth) when hospitalized?

Management of Hospitalized Patients with Active Crohn's Disease Flare: NPO Status

Patients with an active Crohn's disease flare who are hospitalized should NOT be routinely kept NPO (nothing by mouth). Instead, they should be offered a normal diet unless specifically contraindicated.

Evidence-Based Rationale

The British Society of Gastroenterology and International Organization for the Study of Inflammatory Bowel Disease (IOIBD) guidelines do not recommend routine NPO status for patients with active Crohn's disease flares. Research has demonstrated that total bowel rest provides no additional benefit over parenteral nutrition alone in improving disease activity or nutritional status 1.

Appropriate Indications for NPO Status

NPO status should be reserved only for specific clinical scenarios:

1. Patients with:

   • Intractable nausea or vomiting
   • Bowel obstruction
   • Toxic megacolon
   • Pending endoscopy or surgical procedures
   • Severe pancreatitis

2. In all other cases, patients should be offered a normal diet as tolerated.

Nutritional Considerations During Hospitalization

• Nutritional status assessment should be performed upon admission, including weight measurement, albumin, prealbumin, and vitamin levels 2
• Dietitian consultation should be obtained early in the hospitalization course
• For patients unable to maintain adequate oral intake, consider:
  • Exclusive enteral nutrition as a therapeutic option for active Crohn's disease 3
  • Parenteral nutrition only when enteral feeding is not possible or contraindicated

Common Pitfalls to Avoid

1. Unjustified NPO orders: Research shows that up to 44% of NPO or clear liquid diet orders for hospitalized IBD patients are unjustified 2
2. Inadequate nutritional monitoring: Only 36.4% of IBD admissions have documented admission weights and only 17.1% receive dietitian consultation 2
3. Prolonged fasting: Patients with unjustified NPO orders spend an average of 3 days fasting, missing approximately 10 meals 2

Treatment Algorithm for Hospitalized Crohn's Flares

1. Initial Assessment:

   • Evaluate disease severity using validated indices (CDAI, HBI)
   • Obtain stool cultures for enteroinvasive bacterial infections and C. difficile 4
   • Consider CMV testing in refractory cases 4

2. Nutritional Management:

   • Offer normal diet unless specifically contraindicated
   • Consider exclusive enteral nutrition as a therapeutic option 3
   • Reserve NPO status only for specific indications listed above

3. Medical Management:

   • For moderate-severe flares: IV corticosteroids (methylprednisolone 40-60 mg/day) 3
   • Consider budesonide (9 mg/day) for ileal or right colonic disease 3
   • Avoid high-dose steroids if possible due to increased infection risk 4, 3
   • Consider biologic therapies for steroid-resistant disease

4. Thromboprophylaxis:

   • All hospitalized IBD patients should receive VTE prophylaxis 4

Special Considerations

• Female patients and those admitted to non-gastroenterology services are at higher risk for inappropriate NPO orders 2
• Patients with active Crohn's disease are already at risk for malnutrition; unnecessary dietary restrictions can worsen nutritional status
• Rapid tapering of steroids (10 mg/week) should be considered when possible 4

By following these evidence-based recommendations, clinicians can optimize the management of hospitalized patients with active Crohn's disease flares while avoiding unnecessary dietary restrictions that may contribute to malnutrition and prolonged hospital stays.