What is the recommended ileostomy output to be maintained?

Recommended Ileostomy Output

The recommended ileostomy output to be maintained is 500-700 mL per day, as recommended by the American Gastroenterological Association. 1

Normal vs. High Output

• Normal output range: 500-700 mL per day 1
• High output definition: >1000 mL per day 1
• Established ileostomies: Typically produce 600-800 mL per day 2
• Recently formed ileostomies: May produce up to 1,200 mL of watery stool per day 2

Clinical Implications of Output Volumes

Concerning Output Levels

• Outputs >1000 mL/day require intervention to prevent dehydration and electrolyte imbalances 1
• Outputs >1200 mL/day can quickly result in dehydration and potentially acute renal failure if not properly managed 3
• Very high output (>3 L/24 hours) may indicate secretory causes requiring specific interventions 1

Monitoring Parameters

• Target urine output should be ≥800 mL/day with sodium >20 mmol/L 1
• Regular monitoring of electrolytes (sodium, potassium, magnesium) is essential 1
• Laboratory evaluation should include serum electrolytes, urea, creatinine, and magnesium 1

Management of High Output

First-Line Interventions

• Loperamide 2-8 mg before meals (can be increased to 12-24 mg for severe cases) 1
• Restrict oral hypotonic fluids to <500 mL daily 1
• Provide glucose-saline solution with sodium concentration ≥90 mmol/L (1-2L daily) 1

Second-Line Interventions

• Codeine phosphate (30-60mg four times daily) if loperamide alone is insufficient 1
• For secretory output (>3 L/24 hours), consider drugs that reduce gastric acid secretion (H2 antagonists or proton pump inhibitors) 1

Dietary Modifications

• Consume foods that thicken output: bananas, pasta, rice, white bread, mashed potato 1
• Add 0.5-1 teaspoon of salt to meals daily 1
• Consider small, frequent, nutrient-dense meals 1
• Monitor potassium and supplement with potassium-rich foods if needed 1

Common Pitfalls and Caveats

1. Failure to identify underlying causes of high output, such as:

   • Intra-abdominal sepsis
   • Partial/intermittent bowel obstruction
   • Enteritis (including Clostridium difficile enteritis) 1, 3
   • Recurrent disease in remaining bowel
   • Abrupt discontinuation of medications

2. Inadequate electrolyte monitoring:

   • Hyponatremia, hypokalemia, and hypomagnesemia are common complications 1
   • Correcting magnesium deficiency is crucial to prevent resistant hypokalemia 1

3. Improper fluid replacement:

   • Using plain water without sodium replacement can worsen dehydration 1
   • Failure to recognize that significant terminal ileum resection (>30 cm) predisposes to high output 1, 4

4. Overlooking adaptation period:

   • The remaining small intestine requires weeks to months to adapt and increase efficiency of fluid and electrolyte absorption 5
   • Some patients fail to adapt adequately and have persistently high outputs 5

Remember that maintaining proper ileostomy output is essential for preventing dehydration, electrolyte imbalances, and acute renal failure, which can occur in 8-20% of patients with ileostomies 2.