How to manage high output from a colostomy?

Management of High Output Colostomy

The management of high output colostomy requires restricting hypotonic fluids to <500 ml/day, replacing with glucose-saline solution (sodium ≥90 mmol/L) at 1-2L daily, and using antimotility agents such as loperamide 2-8 mg before meals. 1

Fluid and Electrolyte Management

• Fluid restriction and replacement strategy:

  • Restrict hypotonic fluids (water, tea, coffee) to <500 ml/day 1
  • Replace with glucose-saline solution with sodium ≥90 mmol/L, 1-2L daily 1
  • Target urine output ≥800ml/day with sodium >20 mmol/L 1
  • Add 0.5-1 teaspoon of salt to meals daily 1
  • Total fluid intake should be 2-2.5 liters daily, with more during hot weather or exercise 1

• Oral rehydration solution (ORS):

  • Prepare homemade ORS: 1L water + 6 tsp glucose + 1 tsp salt + 0.5 tsp sodium bicarbonate 1
  • Commercial ORS products are available but differ from sports drinks (higher sodium, lower sugar) 2
  • Sipped glucose electrolyte solution is the optimal mode of sodium replacement 2

Medication Management

• Antimotility agents:

  • Loperamide 2-8 mg before meals (FDA-approved for reducing ileostomy discharge) 3
  • 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
  • Note: Loperamide 12 mg/day reduces stoma output but with varying effects among patients 4

• For very high output (>3L/day):

  • Add antisecretory medications:
    • Omeprazole 40 mg once daily or ranitidine 300 mg twice daily 1
    • Consider octreotide for severe cases resistant to other treatments 2, 1
    • Proton pump inhibitors or H2 blockers help reduce gastric hypersecretion 2

Dietary Management

• 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
  • Use thickening powders (maltodextrin, xanthan gum, guar gum) 2, 1

• Eating habits:

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

Monitoring and Follow-up

• Regular assessment:

  • Monitor stoma output volume, hydration status, electrolytes, renal function, and body weight 1
  • Check serum electrolytes, urea, creatinine, and magnesium 1
  • Correct hypomagnesemia and hypokalemia if present 1
  • Long-term monitoring of vitamin B12 levels and screening for zinc and selenium deficiencies 1

• Parenteral support:

  • Parenteral infusions (fluid and electrolytes) may be needed for ongoing high output stomas 2
  • In severe cases (8% of patients), continued parenteral or subcutaneous saline in home setting may be required 2, 5
  • Early follow-up after discharge reduces readmission rates and helps identify malnutrition 2

Special Considerations

• Identify and treat underlying causes:

  • Rule out intra-abdominal sepsis/obstruction 5
  • Consider Clostridium difficile infection of the small intestine 6
  • Short bowel remnant is a common cause of persistent high output 5

• Telemedicine monitoring:

  • Televideoconference evaluation is a feasible method for assessing stoma output post-discharge 7
  • Can enable early intervention to prevent dehydration and readmission 7

High output stoma is common and requires aggressive management to prevent dehydration, electrolyte disturbances, and malnutrition. Early intervention with fluid management, medications, and dietary adjustments can significantly improve outcomes and quality of life.