How to manage a patient with high output ileostomy?

Management of High Output Ileostomy

The management of high output ileostomy requires restricting oral hypotonic fluids to less than 500 ml daily while encouraging glucose-saline replacement solutions with sodium concentration of at least 90 mmol/L, along with antidiarrheal medications such as loperamide. 1

Initial Assessment

• Determine the remaining length of bowel through contrast studies (small bowel meal or enema) to help predict outcomes and guide nutritional support 1
• Examine stoma output characteristics (color, consistency, 24-hour volume) to assess severity 1
• Exclude other causes of high output including:
  • Intra-abdominal sepsis
  • Partial/intermittent bowel obstruction
  • Enteritis (e.g., clostridium or salmonella)
  • Recurrent disease in remaining bowel (e.g., Crohn's disease)
  • Sudden discontinuation of medications (e.g., steroids, opiates)
  • Use of prokinetics (e.g., metoclopramide) 1
• Monitor fluid output and urine sodium to guide fluid management 1

Fluid Management

For Severe Dehydration

• Initially administer intravenous normal saline (2-4 L/day) with the patient kept nil by mouth to demonstrate output is driven by oral intake 1
• Gradually withdraw IV saline over 2-3 days while reintroducing food and restricted oral fluids 1
• Be cautious not to administer excessive fluid, which can cause edema due to high circulating aldosterone levels 1

Ongoing Management

• Restrict oral hypotonic fluids (water, tea, coffee, fruit juices, alcohol) to less than 500 ml daily 1
• Also limit hypertonic fluids (fruit juices, cola, commercial sip feeds) 1
• Encourage drinking glucose-saline replacement solution with sodium concentration of at least 90 mmol/L 1
• Options for replacement solutions:
  • Modified WHO cholera rehydration solution (without potassium chloride)
  • Alternative rehydration solution with higher sodium concentration 1
• For stomal losses <1200 ml daily: add extra salt to diet 1
• For stomal losses 1200-2000 ml daily: use glucose-saline solution or salt capsules 1

Medication Management

• Administer loperamide 2-8 mg before meals to reduce motility and stoma output 1, 2, 3
• Consider adding codeine phosphate if loperamide alone is insufficient 1
• For secretory output (>3 L/24 hours), use:
  • Drugs that reduce gastric acid secretion (H2 antagonists or proton pump inhibitors)
  • Octreotide if unable to absorb oral medications 1
• Correct hypokalaemia by:
  • Addressing sodium/water depletion
  • Normalizing serum magnesium (hypokalemia is often resistant to treatment until magnesium is repleted) 1, 4
• Consider fludrocortisone trial if ileum remains 1

Nutritional Considerations

• Maintain adequate nutrition while managing fluid balance 1
• For patients with severe malabsorption that cannot be managed enterally, parenteral nutrition may be required 1
• Add salt to diet to the limit of palatability 1
• Consider adding sodium chloride to liquid feeds to achieve sodium concentration near 100 mmol/L 1

Monitoring Parameters

• Aim for daily urine volume of at least 800 ml with sodium concentration >20 mmol/L 1
• Monitor hydration status, body weight, and electrolytes regularly 1
• Early follow-up after discharge can reduce readmission rates and identify malnutrition 1, 5

Common Pitfalls to Avoid

• Encouraging patients to drink hypotonic solutions to quench thirst, which paradoxically increases stomal sodium losses 1
• Failing to correct magnesium deficiency, which can perpetuate hypokalemia 4
• Administering excessive intravenous fluids, which can cause edema 1
• Delaying implementation of fluid restriction and glucose-saline solution, which can lead to readmissions for dehydration 5, 6
• Overlooking the potential need for home intravenous hydration for newly created ileostomies, which can significantly reduce dehydration-related readmissions 7

Long-term Management

• For patients with marginally high stoma outputs (1-1.5 L), combine oral fluid restriction (<1 L/day) with increased dietary salt 1
• Some patients with ongoing high output may require continued parenteral or subcutaneous saline in the home setting 1
• Consider protocol-based home intravenous hydration for newly created ileostomies to prevent dehydration-related readmissions 7
• Implement multidisciplinary intestinal rehabilitation for successful long-term management 1