What is the treatment for high ostomy output?

Treatment for High Ostomy Output

The most effective treatment for high ostomy output begins with restricting oral hypotonic fluids to less than 500 ml daily, while encouraging patients to sip glucose-saline solutions with sodium concentration of at least 90 mmol/L throughout the day. 1

Initial Assessment and Management

• Determine the cause of high output by excluding intra-abdominal sepsis, partial obstruction, enteritis, recurrent disease, or medication changes 1, 2
• Assess remaining bowel length through contrast studies to help guide management approach 2
• Initially administer intravenous normal saline (2-4 L/day) with patient kept nil by mouth to demonstrate that output is driven by oral intake 1
• Monitor fluid output and urine sodium to guide fluid management (aim for daily urine volume ≥800 ml with sodium >20 mmol/L) 1, 2

Fluid Management Strategy

Restrict Hypotonic Fluids

• Limit water, tea, coffee, fruit juices, alcohol, and dilute salt solutions to <500 ml daily 1
• Avoid encouraging patients to drink hypotonic solutions to quench thirst as this paradoxically increases stomal sodium losses 1

Provide Appropriate Oral Rehydration

• Encourage drinking glucose-saline replacement solutions with sodium concentration ≥90 mmol/L 1
• Use modified WHO cholera rehydration solution or alternative rehydration solution:
  • Modified WHO solution: 60 mmol sodium chloride, 30 mmol sodium bicarbonate, 110 mmol glucose in 1 liter of water 1
  • Alternative solution: 120 mmol sodium chloride, 44 mmol glucose in 1 liter of water 1
• Sip these solutions throughout the day (1 liter or more) in small quantities 1

Medication Management

• Administer loperamide 2-8 mg before meals to reduce motility and stoma output 1, 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) 1
• If unable to absorb oral medications, consider octreotide to reduce stomal output by 1-2 L/24 hours 1

Nutritional Considerations

• Add salt to diet to the limit of palatability for patients with stomal losses <1200 ml/day 1
• For patients with stomal losses 1200-2000 ml/day, supplement with glucose-saline solution or salt capsules 1
• Add sodium chloride to liquid feeds to achieve sodium concentration near 100 mmol/L while maintaining osmolality near 300 mosmol/kg 1
• Consider separating solids and liquids (no drinks for 30 minutes before or after food), although evidence for this approach is limited 1

Electrolyte Management

• Correct hypokalaemia by addressing sodium/water depletion and normalizing serum magnesium 1, 2
• For hypomagnesaemia, administer intravenous magnesium sulfate initially, then oral magnesium oxide and/or 1-alpha cholecalciferol 1
• Consider a trial of fludrocortisone if ileum remains 1

Long-term Management

• For marginally high stoma outputs (1-1.5 L), combine oral fluid restriction (<1 L/day) with increased dietary salt 1
• Monitor for increased risk of dehydration during hot weather due to additional water and sodium loss in sweat 1
• Consider continued parenteral or subcutaneous saline in the home setting for patients with persistent high output 2, 4
• Implement a multidisciplinary approach to ensure the best possible outcome and quality of life 5, 6

Common Pitfalls to Avoid

• Avoid administering excessive intravenous fluids, which can readily cause edema due to high circulating aldosterone levels 1
• Don't overlook magnesium deficiency, which can cause resistant hypokalemia 1
• Avoid hypertonic fluids containing sorbitol or glucose, which can increase stomal losses of water and sodium 1