From the Guidelines
To manage a chronic high output ileostomy, dietary modifications should focus on reducing output volume while maintaining adequate nutrition and hydration, with the most recent and highest quality study suggesting the use of oral rehydration solutions and careful monitoring of fluid and electrolyte balance 1. The goal of these modifications is to reduce the output volume, maintain adequate nutrition and hydration, and improve the overall quality of life for patients with chronic high output ileostomy.
- Limit fluid intake to 1-1.5 liters daily, consuming small sips throughout the day rather than large amounts at once.
- Restrict hypotonic fluids like water, tea, coffee, and alcohol, which can increase output, as suggested by the AGA clinical practice update on management of short bowel syndrome 1.
- Instead, drink isotonic or oral rehydration solutions containing sodium and glucose to enhance absorption, as recommended by the ESPEN guideline on clinical nutrition in inflammatory bowel disease 1.
- Consume a low-fiber, low-residue diet by avoiding raw fruits and vegetables, whole grains, nuts, and seeds.
- Include binding foods such as white rice, pasta, bananas, smooth peanut butter, marshmallows, and white bread.
- Eat smaller, more frequent meals (5-6 per day) to improve absorption.
- Limit foods that increase output, including spicy foods, caffeine, alcohol, and high-sugar items.
- Add salt to food to replace sodium losses, and consider using pectin supplements or psyllium to thicken stool.
- Take antidiarrheal medications like loperamide (2-4mg, 30 minutes before meals, up to 16mg daily) or codeine phosphate as prescribed, as suggested by the ESPEN practical guideline: clinical nutrition in chronic intestinal failure 1. These modifications work by slowing intestinal transit time, reducing osmotic load, and enhancing fluid and electrolyte absorption in the remaining small intestine, ultimately improving morbidity, mortality, and quality of life for patients with chronic high output ileostomy.
From the FDA Drug Label
Loperamide hydrochloride capsules are ... also indicated for reducing the volume of discharge from ileostomies. The answer to diet modifications for improving high output ileostomy is not directly addressed in the label. Diet modifications are not mentioned in the context of high output ileostomy management.
- The label only mentions the use of loperamide for reducing the volume of discharge from ileostomies 2.
From the Research
Diet Modifications for Improving High Output Ileostomy (Chronic)
- Frequent assessments of fluid balance, weight history, and laboratory data are critical features of medical nutritional therapy for ostomy management 3
- Increased oral intake can help offset fluid and electrolyte losses, and the remaining small intestine can compensate by increasing the efficiency of fluid and electrolyte absorption, a process termed adaptation 4
- Loperamide can reduce ileostomy output, with a median reduction of 16.5% (range -5% to 46%) 5
- High-dose loperamide therapy can be effective in managing chronic high-output ileostomy in patients who have failed conventional medical management 6
- A systematic review of the best evidence for dietary management in patients with high-output ileostomy provides a comprehensive guide for healthcare professionals, covering nutritional risk screening, dietary guidance, dietary behavior guidance, health education, and follow-up care 7
Key Considerations
- Patients with high-output ileostomy are at risk of dehydration and electrolyte depletion, and prompt attention should be given to rehydration and identification of the underlying cause 4
- Continuous tube feeding and oral diet can be used to promote adaptation of the remnant bowel and improve nutritional status 3
- Loperamide can be used to reduce ileostomy output, but dose-response studies are needed to determine the optimal dose 5