From the Guidelines
High ileostomy output can be managed through a combination of dietary modifications, fluid management, and medications, with the most recent and highest quality study suggesting the use of loperamide as the first-line treatment. The study published in 2021 in the journal Clinical Nutrition 1 recommends the use of oral loperamide to reduce wet weight and sodium fecal excretion in patients with short bowel syndrome and an ostomy.
Key Recommendations:
- Restrict oral fluid intake to 1-1.5 liters per day, focusing on oral rehydration solutions containing sodium and glucose rather than plain water or hypotonic fluids.
- Consume small, frequent meals low in fiber and high in soluble fiber, while avoiding foods that accelerate transit time such as spicy foods, caffeine, and alcohol.
- Take antidiarrheal medications like loperamide (2-4 mg, 30 minutes before meals and at bedtime, up to 16 mg daily) or diphenoxylate-atropine to slow intestinal transit.
- For persistent high output, consider adding codeine phosphate (30-60 mg four times daily) or octreotide (50-100 mcg subcutaneously twice daily).
- Replace electrolytes with oral sodium supplements (sodium chloride tablets 1-2 g three times daily) and monitor for dehydration signs like thirst, dizziness, and decreased urine output.
Rationale:
The use of loperamide is preferred over opiate drugs due to its non-addictive and non-sedative properties, as well as its ability to reduce intestinal motility and decrease water and sodium output from an ileostomy 1. The study published in 2021 in the journal Clinical Nutrition 1 also suggests that loperamide is effective in reducing fecal wet weight and sodium excretion in patients with short bowel syndrome and an ostomy.
Monitoring and Follow-up:
Regular monitoring of weight, urine output, and electrolyte levels is essential to prevent complications like dehydration, electrolyte imbalances, and renal dysfunction. If output exceeds 1500 ml/day despite these measures, intravenous fluid replacement and hospital admission may be necessary.
Additional Considerations:
The use of octreotide may be considered for patients with high-output jejunostomy in whom fluid and electrolyte management is problematic, despite conventional treatments 1. However, its use should be guided by objective measurements of its effect, and careful monitoring is necessary to prevent fluid retention and potential adverse effects.
Overall, the management of high ileostomy output requires a comprehensive approach that includes dietary modifications, fluid management, and medications, with a focus on preventing complications and improving quality of life.
From the FDA Drug Label
Loperamide hydrochloride capsules are ... also indicated for reducing the volume of discharge from ileostomies. To manage high ileostomy output following surgery, loperamide can be used to reduce the volume of discharge from ileostomies, as indicated in the drug label 2.
- The medication is taken orally (PO).
- It is essential to follow the prescribed dosage and administration instructions to effectively manage high ileostomy output.
From the Research
Management of High Ileostomy Output
To manage high ileostomy output following surgery, several strategies can be employed:
- Medication adjustment: Loperamide is often used to reduce stoma output, as evidenced by a study that found loperamide 12 mg/day reduced ileostomy output statistically significantly 3.
- Hydration and nutrition modifications: Patients require careful management of electrolyte balances and prevention of postoperative complications, including dehydration and obstructions 4.
- Monitoring and education: Guidelines for managing patients with high-output stomas in the community are essential to improve outcomes, as existing guidelines are primarily focused on the acute care setting 5.
- High-dose loperamide therapy: This can be considered in patients with high-stoma output who have failed conventional medical management, as demonstrated by a case report of three patients who responded to high-dose loperamide 6.
Key Considerations
- Dehydration and electrolyte disturbances are common complications of high ileostomy output, emphasizing the need for close monitoring and management 3, 5.
- Standard treatment doses of loperamide may need to be reassessed, and dose-response studies should be performed to optimize treatment outcomes 3.
- Patient education and monitoring are crucial in the community setting to prevent complications and improve outcomes for patients with high-output stomas 5, 4.