Should a patient with acute cholecystitis be made Nil Per Os (NPO) or is oral diet tolerated?

From the Guidelines

Patients with acute cholecystitis should not be strictly made Nil Per Os (NPO) if they can tolerate oral feeding, as oral diet can be tolerated and may help optimize antimicrobial therapy and minimize hospital stay. According to the 2017 WSES and SICG guidelines on acute calcolous cholecystitis in elderly population 1, in patients who can tolerate oral feeding, antibiotic therapy started initially intravenously may be switched to oral antibiotics to optimize antimicrobial therapy and minimize hospital stay.

Key Considerations

• Identifying the causative organism(s) is an essential step in the management of acute cholecystitis, with positive rates of either bile or gallbladder cultures ranging from 29 to 54% for acute cholecystitis 1.
• Antibiotic therapy for 3–5 days is generally recommended for patients with complicated cholecystitis 1.
• The decision to advance diet should be individualized based on the patient's clinical status, surgical plans, and response to initial treatment.

Management Approach

• Patients who can tolerate oral feeding may be started on oral antibiotics and a diet that is tolerated, to optimize antimicrobial therapy and minimize hospital stay.
• Intravenous fluids should be provided to maintain hydration during the initial period of treatment.
• Clinical improvement, including decreased pain, improved vital signs, and reduced inflammatory markers, should be monitored closely before advancing the diet.
• A clear liquid diet may be cautiously introduced, potentially advancing to a low-fat diet if tolerated, after clinical improvement is observed.

From the Research

Management of Acute Cholecystitis

• The standard of care for acute cholecystitis includes early laparoscopic cholecystectomy, which is recommended to be performed within 72 hours of diagnosis 2.
• Before surgery, patients are typically managed with fasting, intravenous fluid infusion, antimicrobial therapy, and possible administration of analgesics 2.
• There is no specific mention of oral diet tolerance in the provided studies, but fasting is mentioned as part of the initial management before surgery 2.
• The focus is on early surgical intervention, with laparoscopic cholecystectomy being the preferred treatment for acute cholecystitis, and percutaneous or endoscopic gallbladder drainage being considered for patients who are not eligible for surgery or have high operational risks 2, 3, 4.

Dietary Considerations

• The provided studies do not directly address the question of whether a patient with acute cholecystitis should be made Nil Per Os (NPO) or if an oral diet is tolerated.
• However, it is mentioned that patients are typically fasted before surgery as part of their initial management 2.
• The primary focus of the studies is on the diagnosis, treatment, and management of acute cholecystitis, with an emphasis on early surgical intervention and antibiotic therapy 2, 5, 3, 4.

Treatment Approaches

• Early laparoscopic cholecystectomy is the recommended treatment for acute cholecystitis, with the goal of performing surgery within 72 hours of diagnosis 2, 4.
• Percutaneous or endoscopic gallbladder drainage may be considered for patients who are not eligible for surgery or have high operational risks 2, 3, 4.
• Antibiotic therapy plays a key role in preventing surgical complications and limiting the systemic inflammatory response, especially in patients with moderate to severe cholecystitis 5.