What is the first line of management for patients experiencing derangements with an ileostomy?

Management of Ileostomy Derangements

The first-line management for patients experiencing derangements with an ileostomy is fluid and electrolyte management through restriction of hypotonic fluids (<500ml daily) combined with oral glucose-saline solution intake and antimotility medications such as loperamide. 1, 2

Assessment and Monitoring

• Regularly assess:

  • Stoma output volume (high output defined as >1000-2000 mL/24h)
  • Hydration status
  • Electrolytes (sodium, potassium, magnesium)
  • Renal function
  • Body weight 1

• Laboratory evaluation should include:

  • Serum electrolytes, urea, creatinine
  • Magnesium
  • Urinary sodium (random urinary sodium <20 mmol/L suggests sodium depletion) 2
  • Consider vitamin B12, iron, selenium, zinc, and vitamins A, D, E, K assessment 2

Management Algorithm

1. Fluid and Electrolyte Management

• Restrict oral hypotonic fluids (water, tea, coffee, fruit juices, alcohol) to <500 ml daily 2, 1
• Restrict hypertonic fluids (fruit juices, cola, commercial sip feeds) 2
• Provide glucose-saline solution with sodium concentration ≥90 mmol/L (1-2L daily) 2, 1
  • Use modified WHO cholera solution (sodium 90 mmol/L)
  • Sip throughout the day in small quantities
  • Can be chilled or flavored with fruit juice for palatability 2
• Salt supplementation: Add extra salt to food or use sodium chloride capsules for outputs 1200-2000 mL 2
• Target: Urine output ≥800 mL/day with sodium >20 mmol/L 2

2. Medication Management

• Antimotility drugs:

  • Loperamide: First-line therapy, FDA-approved for reducing ileostomy discharge 3
    • Starting dose: 2-8 mg before meals
    • Can increase up to 12-24 mg in severe cases
    • Administer 30 minutes before meals and at bedtime 1
  • Codeine phosphate: 30-60 mg four times daily (second-line)
    • Can be used in combination with loperamide for synergistic effect 1

• For high-output ileostomies (>2 L/day):

  • Proton pump inhibitors: Omeprazole 40 mg daily
  • H2 antagonists: Ranitidine 300 mg twice daily 1
  • Somatostatin analogs: For severe cases resistant to other treatments 1

3. Nutritional Support

• Diet modifications:

  • High carbohydrate, normal fat diet
  • Foods that thicken output: bananas, pasta, rice, white bread, mashed potato 1
  • Consider separating liquids and solids (although evidence is limited) 2

• For severe cases:

  • Enteral nutritional support for distal ileostomies with low output
  • Partial or exclusive parenteral nutrition for proximal ileostomies with very high output 1

4. Treat Underlying Causes

• Investigate for:
  • Intestinal infections (including Clostridium difficile) 4
  • Small bowel obstruction
  • Inflammatory bowel disease flares 2

Special Considerations

• Acute derangements: Patients with ileostomies can develop diverse and potentially life-threatening acute electrolyte and acid-base disorders when ileostomy drainage increases 5

• Hypokalemia: Correct sodium/water depletion and normalize magnesium before addressing potassium 2

• Hypomagnesemia: Initially treat with IV magnesium sulfate, then oral magnesium oxide 1

• Prevention: Consider prophylactic oral isotonic hydration solutions post-discharge to prevent readmissions 6

Common Pitfalls to Avoid

• Using opium tincture as first-line therapy due to addiction and sedation risks
• Inadequate dosing of loperamide
• Failing to address fluid and electrolyte management alongside medication therapy
• Using bile acid sequestrants, which may worsen steatorrhea and fat-soluble vitamin losses 1
• Encouraging hypotonic fluid intake, which paradoxically increases sodium losses 2
• Delaying treatment of high-output stoma, which can quickly lead to dehydration and acute renal failure 4

Interdisciplinary management involving stoma therapists, IBD specialist nurses, and nutritional specialists is essential for optimal care and quality of life for patients with ileostomy derangements 2.