How do you manage high and low output ileostomy?

Management of High and Low Output Ileostomy

The most effective approach to manage high output ileostomy is to restrict oral hypotonic fluids to less than 500 ml daily, replace with glucose-saline solution (sodium concentration ≥90 mmol/L), and use antimotility agents such as loperamide 2-8 mg before meals. 1

Definition and Classification

• High output ileostomy: Output exceeding 1.5-2.0 L/24 hours 2
• Low output ileostomy: Output below this threshold, generally manageable with standard care

Assessment of Ileostomy Output

Initial Evaluation

1. Measure stoma output volume for 24-48 hours
2. Check for signs of dehydration (thirst, dry mucous membranes, decreased urine output)
3. Laboratory assessment:
   • Serum electrolytes (sodium, potassium)
   • Renal function (urea, creatinine)
   • Magnesium levels (critical for managing resistant hypokalemia) 1
   • Urine sodium (target >20 mmol/L) 1

Identify Underlying Causes of High Output

• Intra-abdominal sepsis
• Partial/intermittent bowel obstruction
• Enteritis (including C. difficile enteritis) 3
• Recurrent disease in remaining bowel
• Recent medication discontinuation
• Use of prokinetic agents 1

Management of High Output Ileostomy

Fluid and Electrolyte Management

1. Fluid restriction and replacement:

   • Restrict hypotonic fluids (water, tea, coffee, alcohol) to <500 ml/day 1
   • Replace with glucose-saline solution (sodium ≥90 mmol/L), 1-2L daily 1
   • Target urine output ≥800ml/day with sodium >20 mmol/L 1

2. Sodium replacement:

   • Add 0.5-1 teaspoon of salt to meals daily 1
   • Oral rehydration solution: 1L water + 6 tsp glucose + 1 tsp salt + 0.5 tsp sodium bicarbonate for high output 1

3. Parenteral support:

   • Parenteral infusions (fluid and electrolytes) may be needed for ongoing high output stomas 4
   • Consider subcutaneous fluid (saline with added magnesium) before resorting to IV fluids 2
   • Generally, parenteral nutrition support is needed when less than 100 cm of functioning jejunum remains 2

Dietary Modifications

1. Food timing and consistency:

   • Separate solids and liquids (no drinks 30 minutes before/after meals) 1
   • Chew food thoroughly to avoid stoma blockages 1

2. Food choices:

   • Consume foods that thicken output: bananas, pasta, rice, white bread, mashed potato 1
   • Consider a high carbohydrate (polysaccharides), normal fat diet 1
   • Avoid high-fiber foods if output is already high 1
   • Consider thickening powders (maltodextrin, xanthan gum, guar gum) 4

Pharmacological Management

1. Antimotility agents:

   • Loperamide 2-8 mg before meals (FDA-approved for reducing ileostomy discharge) 5
   • Can be increased to 12-24 mg for severe cases 1
   • Add codeine phosphate (30-60mg four times daily) if loperamide alone is insufficient 1

2. Antisecretory medications (for very high output >3L/day):

   • Omeprazole 40 mg once daily
   • Ranitidine 300 mg twice daily
   • Cimetidine 400 mg four times daily 1
   • Consider octreotide for severe cases 1

Management of Low Output Ileostomy

For patients with distal (low ileal or colonic) fistula and low output:

• Can usually receive all nutritional support via the enteral route (generally as food) 4
• Standard ileostomy care with monitoring for adequate hydration
• Ensure adequate fluid intake (2-2.5 liters daily, more during hot weather or exercise) 1
• Monitor for signs of blockage or insufficient output

Monitoring and Follow-up

1. Regular monitoring:

   • Stoma output volume
   • Hydration status
   • Electrolytes (sodium, potassium, magnesium)
   • Renal function
   • Body weight 1

2. Long-term monitoring:

   • Vitamin B12 levels
   • Screen for other deficiencies, particularly zinc and selenium 1
   • Monitor for intestinal adaptation, which occurs within weeks to months of ileostomy creation 6

Common Pitfalls to Avoid

• Encouraging excessive fluid intake - can worsen output and dehydration by increasing stomal sodium losses 1
• Ignoring electrolyte imbalances - hypomagnesemia can cause resistant hypokalemia 1
• Overlooking C. difficile enteritis - an emerging cause of high-output ileostomy 3
• Failing to correct sodium/water depletion first - address this before treating magnesium deficiency 1
• Missing partial bowel obstruction - a common reversible cause of high output 2

Special Considerations

• Multidisciplinary intestinal rehabilitation is essential for successful management of patients with intestinal insufficiency 4
• Early follow-up after discharge significantly reduces readmission rates and helps identify malnutrition 4
• Consider protein-based oral rehydration solutions, which may improve absorption in some patients 7
• Rice-based oral rehydration therapy has shown promise in reducing dependency on parenteral nutrition 8