Should patients with diverticulitis remain nil per os (NPO)?

From the Guidelines

Patients with diverticulitis should not remain NPO, but instead, be advised to follow a clear liquid diet during the acute phase of uncomplicated diverticulitis, with the goal of advancing their diet as symptoms improve, as recommended by the AGA clinical practice update 1. The rationale behind this approach is to prioritize patient comfort, as many patients report greater comfort on a clear liquid diet, potentially due to the mechanical obstruction and/or systemic inflammation associated with diverticulitis. Some key points to consider when managing patients with diverticulitis include:

• A clear liquid diet is advised during the acute phase of uncomplicated diverticulitis, with the goal of advancing the diet as symptoms improve 1.
• Patients with acute uncomplicated diverticulitis commonly present with anorexia and malaise, and a clear liquid diet may help alleviate these symptoms.
• If a patient is unable to advance their diet after 3–5 days, they should follow up immediately to reassess their condition and adjust their management plan as needed.
• The decision to advance a patient's diet should be individualized based on symptom severity, presence of nausea/vomiting, abdominal pain intensity, and risk of complications.
• Ultimately, the goal is to balance bowel rest with the need to provide adequate nutrition and hydration to support the healing process and prevent complications.

From the Research

NPO Status for Patients with Diverticulitis

• The decision to keep patients with diverticulitis NPO (nil per os, or nothing by mouth) is not explicitly addressed in the provided studies.
• However, the studies suggest that the management of diverticulitis is evolving, and the use of antibiotics, dietary restrictions, and surgical interventions are being reevaluated 2, 3.
• For patients with uncomplicated diverticulitis, outpatient management is considered the best strategy, and antibiotics may not be necessary for low-risk patients 3, 4.
• In patients with complicated diverticulitis, hospitalization and supportive care with intravenous fluids and antibiotics may be necessary 5, 6.
• The role of diet in preventing diverticular disease is debated, but a high-fiber diet appears to decrease the likelihood of symptomatic diverticulitis 2.
• There is no clear evidence to support the use of NPO status for patients with diverticulitis, and the decision to restrict oral intake should be made on a case-by-case basis, considering the individual patient's condition and the severity of their disease.

Dietary Considerations

• A high-fiber diet is recommended to decrease the likelihood of symptomatic diverticulitis 2.
• The myth of avoiding certain foods, such as nuts, corn, popcorn, and seeds, to prevent episodes of diverticulitis has been debunked 2.
• Dietary restrictions do not prevent recurrent diverticulitis, and clinicians should be aware of the latest updates in the management of diverticular disease 3.

Antibiotic Use

• The use of antibiotics in uncomplicated diverticulitis is being reevaluated, and the evidence suggests that antibiotics may not be necessary for low-risk patients 3, 4.
• Antibiotics are still recommended for patients with complicated diverticulitis, and the choice of antibiotic regimen should be based on the individual patient's condition and the severity of their disease 5, 6.