What are the treatment options for high output ileostomy?

Management of High Output Ileostomy

The treatment of high output ileostomy requires a comprehensive approach including fluid restriction, electrolyte management, medications, and nutritional support to prevent dehydration and malnutrition. 1

Initial Assessment and Monitoring

• Monitor fluid output and urine sodium to guide management decisions 1, 2
• Aim for daily urine volume of at least 800 ml with sodium concentration >20 mmol/L 2
• Exclude other causes of high output including intra-abdominal sepsis, enteritis, recurrent disease, and medication changes 2
• Evaluate for Clostridium difficile infection, which can cause high-output ileostomy 3

Fluid Management

• Restrict oral hypotonic fluids (water, tea, coffee) to less than 500 ml daily 1, 2
• Encourage drinking glucose-saline replacement solutions with sodium concentration of at least 90 mmol/L 1, 2
• Administer parenteral infusions (fluid and electrolytes) for ongoing high output stomas that don't respond to oral management 1
• Consider home parenteral or subcutaneous saline for patients with persistent high output (approximately 8% of patients) 1

Medication Management

• Administer loperamide 2-8 mg before meals to reduce motility and stoma output as first-line pharmacological treatment 2, 4
• Consider high-dose loperamide therapy for patients who fail conventional management 5
• Add codeine phosphate if loperamide alone is insufficient 2
• Use medications that reduce gastric acid secretion for secretory output 2

Nutritional Considerations

• Add salt to diet to the limit of palatability to replace sodium losses 2
• Consider adding sodium chloride to liquid feeds to achieve sodium concentration near 100 mmol/L 2
• For patients with proximal fistulas and/or very high output, provide nutritional support via partial or exclusive parenteral nutrition 1
• Patients with distal (low ileal or colonic) fistulas and low output can usually receive nutritional support via the enteral route 1

Advanced Interventions

• For patients with newly created ileostomies, consider protocol-based intravenous fluid hydration at home to prevent dehydration and readmissions 6
• Implement multidisciplinary intestinal rehabilitation for successful long-term management 1
• Consider thickening powders containing maltodextrin, xanthan gum, and guar gum for nutritional management of patients with short bowel syndrome 1

Common Pitfalls to Avoid

• Avoid encouraging patients to drink hypotonic solutions to quench thirst, which paradoxically increases stomal sodium losses 1, 2
• Correct magnesium deficiency to prevent hypokalemia 2
• Avoid administering excessive intravenous fluids, which can cause edema 2
• Don't overlook dehydration risk, which can lead to venous thromboembolism in IBD patients 1

Expected Outcomes

• About 49% of high output ileostomies resolve spontaneously, while 51% require ongoing medical treatment 1
• Loperamide treatment can reduce ileostomy output by a median of 16.5%, though individual responses vary 7
• Early follow-up after discharge can significantly reduce readmission rates and identify malnutrition 1

The management of high output ileostomy requires vigilant monitoring and a stepwise approach to treatment, prioritizing fluid and electrolyte balance while providing adequate nutrition to prevent complications such as acute renal failure and malnutrition 1, 8.