Management of High output Stomas
Muhammad Haris AslamResident, Surgical Unit I
SIMS/Services Hospital, Lahore
Introduction
• It is a surgically created opening, which connects part of a person’s bowel to the outside of their body...
Intestinal fluid flux
• 1.5 L saliva• 2.5 L gastric secretion• 1 L Bile + pancreatic secretions • 3L succus entericus
• Most reabsorbed in Small intestine• 1.5 to 2 L enters colon and it absorbs most of it
and only 200 -400 ml is excreted in stools
• Normal ileostomy output is 1500-1800ml / 24 hours untill adaptation
• After adaptation it is 500- 800 ml/ 24 hours
• If it persists to > 1500 ml/24 hours it is termed as high output stoma
Who is at Risk
• Crohn’s disease patients
• Colectomy
• Vascular accidents
Causes of high output stoma
• Gastric acid Hyper secretion
• Baterial over growth
• Pre stomal ileitis
• Revealed latent disease ( celiac disease, hypolactasia, pancreatic disease, pancreatic insufficiency, thyrotoxicosis)
Causes..cntd..
• Infection ( including clostridium difficile)
• Short bowel
• Adaptation phase
• Uncontrolled inflamation, sepsis and malnutrition
• Lactose in tolerence.
Complications
• Dehydration
• Renal dysfuction including Oxalate stones
• Electrolyte abnormalities
• Malnutrition
• Psychological abnormalities..
Assessment of High output stoma
• Review history.– No. Of bags emptying /night, associated pain etc– Types of fluid , quantity of fluids and food.
• Current medication– Doses of omeprazole– Loperamide– Lactose containing medication
Management
• Step 1• Dietry adjustments
• Isotonic fluids
• Omeprazole
• Megadose loperamide
• Antibiotics for bacterial overgrowth
Step 2
• If output is still >1500ml/ day then
• NPO for 48 hours and IV fluids to assess baselien output
• Review all investigations and management
• Measure daily electrolytes ( including Mg)
• If baseline output is >1200ml/ day then consider long term IV fluids
Step 3
• Is baseline output is < 1200ml/day then• Commence oral rehydration salt trial for 48
hours
Step 4• If output is <1500ml
after isotonics then go to step 6
• If output is > 1500ml after isotonics then start sequentionally– Omeprazole 80mg/day– + loperamide 8mg 4x5/day can
be upto 100mg/day– + codene 60 mg 4xday– +octreotide 3xday– Stop octreotide after 72 hours
if impact is <300 ml/day
Output <1500ml .go to step 5 Output > 1500ml . Plan TPN/ fluids
Step 5
• Commence liquid feed and nutritional suppliments
• Measure effect on output– if < 1500ml go to step 6– If > 1500ml then plan for TPN
Step 6
• Start solid food and measure effect on output
• If > 1500ml then start IV fluids suppliments
How to prevent high output stoma
• Low fibre diet– Reduce the amount of bulk moving through bowel,
helping to rest it
• Add extra salt to meals and increase intake of salty foods
• Not to drink just before, with or 30-60 minutes after meals
• Restrict fluid intake to no more than 1500ml per day– The more you drink, the more will come out of
stoma.
• Smaller more frequent meals may be better tolerated, particularly in the first few weeks.
• Take your time and chew food thoroughly.
• Avoid heavy meals or snacks before bedtime.
• Medications– Loperamide– Codeine Phosphate
Appropriate food
• What to try
• Eat starch and protein– Starch:
• Bread, Cereal, Rice, Pasta, Potatoes
– Proteins: • Meat, Fish, Cheese, Peanut butter, Eggs
• Add extra salt to meals
• Reduce Lactose in diet
• Milk, Ice cream
• Reason
• Slow the movement of food giving more time to digest
• Helps to absorb fluids better
• Decrease bloating and diarrhea
Foods that may decrease stool frequency / diarrhea
• Bananas• Bread – white• Cheese• Oat bran• Oatmeal• Pasta – white
• Peanut butter – smooth• Potatoes• Pretzels• Rice pudding• Rice – white
Foods that may increase stool frequency / diarrhea
• Alcoholic beverages• Beverages that have caffeine
• coffee, tea and cola
• Chocolate• Dried fruit and pineapple• Honey• Jams and Jellies• Juice especially apple, grape
& prune
• Nuts• Olives• Peas,beans &legumes• Pickles• Popcorn• Skins and seeds of fruits &
vegetables• Spicy foods/sauces• Vegetables:
• broccoli, cauliflower & onions
• Whole grains
Appropriate fluids
• Drink 1000ml of an oral rehydration solution / day– ORS– Pedialyte– Home made oral rehydration solution
• Other choices:– Dilute juice (half juice half water)– Tomato juice– Soup
Appropriate fluids
• Limit intake of all other types of fluids (water, tea, coffee and milk) to less than 500 ml per day
• Choose restricted lactose milk
• Avoid drinks high in sugar• juice, regular pop and fruit drinks
Discharge instructions• Avoid sweeteners such as sorbitol and mannitol
• Sugar Free Items
• Sip on oral rehydration fluids throughout the day
• Separate Fluids & Solids
• Wait 30 minutes before & after a meal before drinking fluids
• Limit fluid at meals to less than 125 ml (½ cup)
Discharge instructions
• Measure ileostomy output for 2 days. If over 1200 ml per day, start taking loperamide before meals and at bedtime
• Eat 6-8 small meals per day rather than 3 larger ones
• Limiting fluid intake to 4 ounces with meals
High Output Pouches
Hollister Convatec ColoplastHollister Convatec Coloplast
High Output Pouches
• Decrease frequency of emptying
• At night these can be attached to bedside drainage bag to decrease sleeplessness for patient and caregiver
• Works well for liquid output but needs to be replaced with a standard pouch when output thickens