Management of Increased Transit Ileostomy
The management of patients with increased transit (high output) ileostomy should focus on fluid restriction, electrolyte replacement, anti-motility medications, and monitoring of fluid balance to prevent dehydration and malnutrition. 1
Initial Assessment
- Exclude other causes of high output such as intra-abdominal sepsis, bowel obstruction, enteritis, recurrent disease, or medication changes 2, 3
- Monitor fluid output and urine sodium to guide management 1
- Aim for daily urine volume of at least 800 ml with sodium concentration >20 mmol/L 2
- Determine the remaining length of bowel through contrast studies to help predict outcomes 3
Fluid Management
- Restrict oral hypotonic fluids (water, tea, coffee, fruit juices, alcohol) to less than 500 ml daily 1, 2
- Provide glucose-saline replacement solutions with sodium concentration of at least 90-100 mmol/L 2, 3
- Options for replacement solutions include:
- Administer intravenous normal saline (2-4 L/day) if needed for severe dehydration 2
- Parenteral infusions (fluid and electrolytes) may be required for ongoing high output stomas 1
Medication Management
- Administer loperamide 2-8 mg before meals to reduce motility and stoma output 2, 4
- Loperamide acts by slowing intestinal motility and affecting water and electrolyte movement through the bowel 4
- Loperamide is FDA-approved for reducing the volume of discharge from ileostomies 4
- Note that effectiveness varies among patients, with studies showing a median reduction of 16.5% in ileostomy output 5
- Consider adding codeine phosphate if loperamide alone is insufficient 2, 3
- For secretory output (>3 L/24 hours), add H2 antagonists or proton pump inhibitors 2
Nutritional Considerations
- Separate solids and liquids (no drinks for half an hour before or after food) 2
- Add salt to diet to the limit of palatability 3
- Consider adding sodium chloride to liquid feeds to achieve sodium concentration near 100 mmol/L 3
- Monitor for malnutrition, which is a common complication of high output stomas 1, 6
- For patients with short bowel syndrome, continuous tube feeding may help promote adaptation of the remnant bowel 6
Electrolyte Management
- Address sodium depletion first, as hypokalaemia is most commonly due to sodium depletion with secondary hyperaldosteronism 2
- Correct hypomagnesaemia with intravenous magnesium sulfate initially, then oral magnesium oxide 2
- Monitor for acid-base disorders, as patients with ileostomies can develop either metabolic acidosis or metabolic alkalosis depending on the nature and duration of losses 7
Long-term Management
- For patients with marginally high stoma outputs (1-1.5 L), combine oral fluid restriction with increased dietary salt 2
- Consider parenteral or subcutaneous saline in the home setting for patients with persistent high output 1
- Implement multidisciplinary intestinal rehabilitation for successful long-term management 1, 3
Common Pitfalls to Avoid
- Avoid encouraging patients to drink hypotonic solutions to quench thirst, which paradoxically increases stomal sodium losses 2, 3
- Avoid administering excessive intravenous fluids, which can cause edema due to high circulating aldosterone levels 2
- Don't overlook potential infectious causes of increased output, such as Clostridium difficile enteritis 8
- Remember that early high output from an ileostomy is common (49% resolve spontaneously, but 51% need ongoing medical treatment) 1
Special Considerations
- Patients with a high-output enterostomy are prone to dehydration and malnutrition, which may culminate in acute renal failure 1
- Every effort should be made to avoid dehydration in these patients, as it increases the risk of venous thromboembolism 1
- Early follow-up after discharge can significantly reduce readmission rates and help identify malnutrition 1