How do you manage a high output ileostomy?

Management of High Output Ileostomy

For patients with high output ileostomy, the management should include monitoring fluid output and urine sodium, restricting hypotonic fluids, increasing saline solutions, and using anti-diarrheal medications to reduce output and 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
• 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 remaining bowel length through contrast studies to help predict outcomes 3

Fluid Management Algorithm

1. Restrict oral hypotonic fluids (water, tea, coffee, fruit juices, alcohol) to less than 500 ml daily 1, 2
2. Provide glucose-saline replacement solutions with sodium concentration of at least 90-100 mmol/L 2, 3
3. Options for replacement solutions include:
   • Modified WHO cholera rehydration solution (60 mmol/L sodium chloride, 30 mmol/L sodium bicarbonate, 110 mmol/L glucose in 1 liter water) 2
   • Alternative rehydration solution (120 mmol/L sodium chloride, 44 mmol/L glucose in 1 liter water) 2
4. Separate solids and liquids (no drinks for half an hour before or after food) 2
5. Add salt to diet to the limit of palatability 3
6. Parenteral infusions (fluid and electrolytes) may be needed for ongoing high output stomas 1

Medication Management

• Administer loperamide 2-8 mg before meals to reduce motility and stoma output 2, 4
• For patients not responding to conventional doses, consider high-dose loperamide which has shown significant clinical improvement in patients with chronic high-output ileostomy 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

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 hydration status, body weight, and electrolytes regularly 3

Nutritional Considerations

• Maintain adequate nutrition while managing fluid balance 3, 6
• Consider continuous tube feeding for 24 hours in severe cases to promote adaptation of the remnant bowel 6
• For patients with marginally high stoma outputs (1-1.5 L), combine oral fluid restriction with increased dietary salt 1, 2

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 neglect magnesium correction, as magnesium deficiency can perpetuate hypokalemia 3

Long-term Management

• 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, 6
• Regular monitoring and follow-up to prevent complications such as dehydration, acute kidney injury, and malnutrition 7, 8