From the Guidelines
High-output ostomy workup should prioritize hydration and infection evaluation.
Key Steps in Workup
- Evaluate for infection, ileus, or medication-related adverse effects, particularly in the context of a colostomy or high ileostomy output 1
- Assess for dehydration and malnutrition, which can lead to acute renal failure and wasting 1
- Consider parenteral infusions for fluid and electrolyte replacement in cases of ongoing high output stomas 1
Management Strategies
- Restrict oral hypotonic fluids to less than 500 ml/day and encourage glucose-saline solution intake with a sodium concentration of at least 90 mmol/l 1
- Add sodium chloride to liquid feeds to maintain a sodium concentration near 100 mmol/l 1
- Use drugs to reduce motility, such as loperamide, and consider codeine phosphate or octreotide for severe cases 1
- Monitor urine sodium content and adjust management accordingly 1
Additional Considerations
- Separate solids and liquids to minimize stomal output, although evidence for this is limited 1
- Correct hypomagnesaemia to prevent hypokalaemia and consider fludrocortisone if the ileum remains 1
- Provide patient education on oral fluid restriction, glucose-saline solution intake, and salt supplementation to manage high output stomas effectively 1
From the Research
Definition and Diagnosis of High-Output Stoma
- A high-output stoma (HOS) is defined as a stoma output of more than 1,000 mL per day for more than 3 days 2, or > 1.5 -2.0 L/24 hours 3, or > 1,000- 2,000 ml/day, lasting for one to three days 4.
- The clinical assessment consists of excluding causes other than a short bowel and treating them (especially partial or intermittent obstruction) 3.
- A contrast follow through study gives an approximate measurement of residual small intestinal length (if not known from surgery) and may show the quality of the remaining small bowel 3.
Treatment of High-Output Stoma
- The first step is to rehydrate the patient so stopping severe thirst 3.
- Oral hypotonic fluid is restricted and a glucose-saline solution is sipped 3.
- Medication to slow transit (loperamide often in high dose) or to reduce secretions (omeprazole for gastric acid) may be helpful 3.
- Subcutaneous fluid (usually saline with added magnesium) may be given before intravenous fluids though can take 10-12 hours to infuse 3.
- Generally parenteral support is needed when less than 100 cm of functioning jejunum remains 3.
- Treatment includes intravenous fluid and electrolyte resuscitation followed by restriction of hypotonic fluid and the use of antimotility (and antisecretory) drugs 4.
Management and Prevention
- There is limited high-quality evidence favouring any specific widely used drug over the others in the management of high-output stoma 5.
- Evidence, however, is weak due to inconsistent definitions, risk of bias and poor methodology in the existing studies 5.
- All healthcare professionals should have knowledge of the diagnosis, treatment, and prevention of ileostomy complications 4.
- Skin protective products are typically used for local treatment of peristomal dermatitis 4.
- Convex stoma appliances can be used for skin protection against fecal leakage 4.