From the Guidelines
Management of a high output ileostomy requires a comprehensive approach focusing on fluid and electrolyte replacement, dietary modifications, and medications, with the goal of maintaining stoma output below 1500 ml/day to prevent dehydration and malnutrition. To achieve this, several strategies can be employed:
- Ensure adequate fluid intake of 2-3 liters daily, with oral rehydration solutions containing sodium and glucose to enhance absorption, as suggested by 1.
- Restrict hypotonic fluids like water, tea, and coffee as they can worsen fluid losses.
- Dietary modifications should include small, frequent meals with reduced fiber and fat content, while increasing complex carbohydrates and proteins.
- Medications that can help reduce output include loperamide (2-4 mg four times daily, up to 16 mg/day), as recommended by 1, diphenoxylate with atropine (2.5-5 mg four times daily), or codeine phosphate (15-60 mg four times daily).
- For severe cases, octreotide (50-200 mcg subcutaneously three times daily) may be considered, especially in the short-term after intestinal resection, as suggested by 1.
- Separate fluid intake from meals by drinking 30-60 minutes before or after eating.
- Monitor for dehydration signs including thirst, dizziness, decreased urine output, and weight loss.
- Regular assessment of electrolytes, particularly sodium, potassium, and magnesium, is essential, with supplementation as needed, as highlighted by 1. These interventions work by slowing intestinal transit time, enhancing fluid absorption, and replacing lost nutrients and electrolytes to prevent complications like acute kidney injury and metabolic acidosis.
From the Research
Management of High Output Ileostomy
To manage a patient with high output ileostomy, several strategies can be employed:
- Medication: Loperamide is often used to reduce stoma output, as evidenced by a study 2 which found that loperamide 12 mg/day reduced ileostomy output statistically significantly. Another study 3 also reported successful management of chronic high-output ileostomy with high-dose loperamide.
- Fluid and Electrolyte Replacement: Adequate fluid and electrolyte replacement is crucial to prevent dehydration and electrolyte disturbances. A case report 4 highlighted the importance of recognizing high output ileostomies early and managing them with adequate sodium and fluid replacement.
- Oral Rehydration Therapy: Oral rehydration therapy (ORT) can be effective in managing high output ileostomy, as reported in a clinical vignette 5 where a patient was successfully liberated from dependency on total parenteral nutrition and intravenous fluid and electrolyte replacement using a rice-based ORT.
- Intravenous Fluid Hydration: Protocol-based intravenous fluid hydration for newly created ileostomies can decrease readmissions secondary to dehydration, as found in a study 6 which evaluated the impact of mandatory home intravenous hydration for patients with newly created ileostomies.
Key Considerations
When managing a patient with high output ileostomy, it is essential to:
- Monitor stoma output and adjust treatment accordingly
- Ensure adequate fluid and electrolyte replacement
- Consider the use of loperamide or other medications to reduce stoma output
- Implement oral rehydration therapy or intravenous fluid hydration as needed
- Provide ongoing monitoring and support to prevent dehydration and electrolyte disturbances.