How to manage high output from an ostomy?

Management of High Output Ostomy

The management of high output ostomy requires restricting oral hypotonic fluids to less than 500 ml daily, using glucose-saline oral rehydration solutions with sodium concentration of at least 90 mmol/l, and administering antimotility medications such as loperamide. 1

Definition and Assessment

High output stoma (HOS) is defined as effluent of 1000-2000 ml/24h. When output exceeds 2000 ml/24h, patients are at significant risk for dehydration, electrolyte depletion, and malnutrition 1. Assessment should include:

• Monitoring fluid output and urine sodium (target >20 mmol/L) 1
• Laboratory evaluation: serum electrolytes, urea, creatinine, magnesium 1
• Evaluation for underlying causes (infection, obstruction, recurrent disease) 1

Management Algorithm

1. Fluid Management

• Restrict hypotonic fluids (water, tea, coffee, fruit juices, alcohol) to <500 ml/day 1
• Restrict hypertonic fluids (fruit juices, sodas, commercial sip feeds) 1
• Provide glucose-saline solution with sodium concentration ≥90 mmol/L to sip throughout the day 1
  • Modified WHO cholera solution (without potassium chloride):
    • Sodium chloride: 60 mmol (3.5g)
    • Sodium bicarbonate/citrate: 30 mmol (2.5g)
    • Glucose: 110 mmol (20g)
    • Tap water: 1 liter
  • Alternative solution:
    • Sodium chloride: 120 mmol (7g)
    • Glucose: 44 mmol (8g)
    • Tap water: 1 liter

2. Pharmacological Management

• Antimotility agents: Loperamide 2-8 mg before meals 1, 2
  • FDA-approved for reducing ileostomy discharge volume 2
  • Can reduce output by a median of 16.5% 3
• Add codeine phosphate if loperamide alone is insufficient 1
• Antisecretory medications for high-volume output (>3L/24h):
  • Proton pump inhibitors or H2 antagonists 1
  • Consider octreotide for refractory cases (can reduce output by 1-2L/24h) 1

3. Nutritional Support

• Ensure adequate salt intake (add extra salt to food) 1
• For patients with ongoing high output despite above measures:
  • Consider parenteral fluid and electrolyte infusions 1
  • Parenteral nutrition may be required in severe cases with malabsorption 1

Special Considerations

• Electrolyte management: Correct hypomagnesemia and hypokalaemia 1
• Monitoring: Aim for urine output ≥800 ml/day with sodium >20 mmol/L 1
• Adaptation: Small intestine adaptation typically occurs within weeks to months after ileostomy creation 4
• Rule out complications: Consider Clostridium difficile enteritis as a potential cause of high output 5

Common Pitfalls to Avoid

1. Encouraging excessive water intake - This worsens sodium losses and increases stoma output 1
2. Inadequate sodium replacement - Commercial sports drinks typically have insufficient sodium content 1
3. Failure to recognize dehydration - Can rapidly lead to acute kidney injury 5
4. Missing underlying causes - Always evaluate for infection, obstruction, or disease recurrence 1

Early intervention with fluid restriction, oral rehydration solutions, and antimotility medications can prevent hospitalization and complications in patients with high output ostomies 6. A multidisciplinary approach involving gastroenterology, surgery, nutrition, and nursing is essential for optimal management.