From the Guidelines
Managing high ileostomy output requires a multifaceted approach combining dietary modifications, fluid management, and medications, with loperamide being the primary agent to slow intestinal transit, as supported by the most recent and highest quality study 1.
Key Interventions
- Dietary modifications:
- Oral rehydration solutions containing sodium and glucose to enhance fluid absorption
- Restricting hypotonic fluids (water, tea, coffee)
- Consuming a low-fiber, high-salt diet with small, frequent meals
- Fluid management:
- Drinking 1L plus the volume of stoma output
- Monitoring and recording stoma output
- Medications:
- Loperamide (2-4mg taken 30-60 minutes before meals and at bedtime, up to 16mg daily) to slow intestinal transit
- Codeine phosphate (30-60mg 3-4 times daily) or diphenoxylate with atropine for inadequate response
- Octreotide (50-200mcg subcutaneously 2-3 times daily) in severe cases to reduce secretions
- Proton pump inhibitors like omeprazole (20-40mg daily) to decrease gastric acid production
Rationale
The approach is based on the most recent and highest quality study 1, which suggests that loperamide is the primary agent to slow intestinal transit, and that dietary modifications, fluid management, and medications are crucial in managing high ileostomy output. The study also highlights the importance of monitoring and recording stoma output, and seeking medical attention if output exceeds 1500mL/day for more than 48 hours or if dehydration symptoms develop.
Additional Considerations
- Patients should be cautious with high intakes of hypotonic and hypertonic drinks, as they can increase stoma output and dehydration 1.
- The use of octreotide should be guided by objective measurements of its effect, and patients should be monitored for potential adverse effects and fluid retention 1.
- Proton pump inhibitors like omeprazole can help decrease gastric acid production, but their use should be balanced with the potential risk of bacterial overgrowth 1.
From the FDA Drug Label
Octreotide acetate injection is a somatostatin analogue indicated: ... Vasoactive Intestinal Peptide Tumors (VIPomas): For the treatment of profuse watery diarrhea associated with VIP-secreting tumors. Carcinoid Tumors: For the symptomatic treatment of patients with metastatic carcinoid tumors where it suppresses or inhibits the severe diarrhea and flushing episodes associated with the disease.
The treatment option for managing high ileostomy output is octreotide acetate injection. It is used to treat severe diarrhea and flushing episodes associated with carcinoid tumors and VIPomas, which can be similar to high ileostomy output. The recommended dosage range is 100 mcg to 600 mcg daily in two to four divided doses during the initial 2 weeks of therapy for carcinoid tumors, and 200 mcg to 300 mcg daily in two to four divided doses during the initial 2 weeks of therapy for VIPomas 2.
- Key considerations:
- Monitor cardiac function, as octreotide acetate injection may increase the risk of cardiac abnormalities.
- Monitor glucose metabolism, as hypoglycemia or hyperglycemia may occur.
- Monitor thyroid function, as hypothyroidism may occur.
- Use with caution in patients with advanced hepatorenal disease or abnormal liver function.
From the Research
Treatment Options for High Ileostomy Output
- Medications: Loperamide is often used to reduce stoma output, with studies showing a significant reduction in ileostomy output 3, 4. High-dose loperamide may be considered in patients who have failed conventional medical management 4.
- Oral Rehydration Solutions: Protein-based oral rehydration solutions may help improve absorption and reduce dehydration in patients with an ileostomy 5. Whey protein isolate ORS has been shown to improve absorption proxies in both faeces and blood 5.
- Fluid Management: Patients with high-output stomas may require rehydration with glucose-saline solutions, and subcutaneous fluid may be given before intravenous fluids 6.
- Intravenous Hydration: Protocol-based intravenous fluid hydration for newly created ileostomies can decrease readmissions secondary to dehydration 7.
- Surgical Intervention: In some cases, bringing defunctioned bowel back into continuity may be considered to manage high-output stomas 6.
Management Strategies
- Assessing the cause of high-output stoma and treating underlying conditions, such as partial or intermittent obstruction 6.
- Restricting oral hypotonic fluid and sipping glucose-saline solutions to manage dehydration 6.
- Using medications to slow transit or reduce secretions, such as loperamide or omeprazole 6.
- Monitoring patients for signs of dehydration and electrolyte disturbances, and adjusting treatment accordingly 3, 4, 6, 5, 7.