What are the recommendations for managing an ileostomy?

Management of Ileostomy

Fluid and Electrolyte Management

The cornerstone of ileostomy management is restricting hypotonic oral fluids to less than 500 mL daily while replacing losses with glucose-saline solutions containing at least 90 mmol/L sodium. 1

Fluid Restriction Strategy

• Limit hypotonic fluids (water, tea, coffee, fruit juices, alcohol) to <500 mL/day—this is the single most important intervention 1
• Avoid hypertonic fluids (fruit juices, Coca-Cola, commercial sip feeds) as these paradoxically increase stomal sodium and water losses 1
• For patients with marginally high outputs (1-1.5 L/day), restrict total oral fluids to <1 L/day and add extra salt to diet 1

Glucose-Saline Replacement

• Sip glucose-saline solution with sodium concentration ≥90 mmol/L throughout the day (WHO cholera solution without potassium chloride is commonly used) 1
• This concentration matches the ~90 mmol/L sodium content of ileostomy effluent and allows coupled sodium-glucose absorption 1
• Patients should consume ≥1 liter daily in small quantities; may be chilled or flavored with fruit juice for palatability 1
• For outputs 1200-2000 mL/day, glucose-saline solution or salt capsules (500 mg, up to 14/24h) maintain sodium balance 1

Monitoring Hydration Status

• Target daily urine volume ≥800 mL with sodium concentration >20 mmol/L 1
• Patients should consume 2-2.5 liters total fluids daily to avoid chronic dehydration 2
• In hot weather, increased sweat losses require additional attention to hydration 1

Pharmacologic Management

Antimotility Agents

Loperamide is the preferred first-line antimotility agent, reducing ileostomy output by 20-30%. 1, 3

• Loperamide 2-8 mg before meals is superior to codeine phosphate—it is non-sedative, non-addictive, and does not cause fat malabsorption 1
• Due to disrupted enterohepatic circulation in short bowel, high doses (12-24 mg at a time) may be needed 1
• Loperamide is FDA-approved specifically for reducing ileostomy discharge volume 3
• If tablets emerge unchanged in output, crush them or mix with water 1
• Codeine phosphate may be added if loperamide alone is insufficient 1

Antisecretory Agents (for High Output >2-3 L/day)

• Proton pump inhibitors (omeprazole 40 mg once daily orally or twice daily IV) or H2 antagonists (ranitidine 300 mg twice daily, cimetidine 400 mg four times daily) reduce output by 1-2 L/day in net secretors 1
• These are as effective as octreotide but easier to administer 1
• Octreotide 50 mcg subcutaneously twice daily provides greatest benefit in net secretory outputs (>3 L/day), with sustained long-term effect 1
• Give all medications before meals, as intestinal output rises postprandially 1

Electrolyte Supplementation

• Correct sodium/water depletion first before addressing potassium or magnesium abnormalities 1
• Hypokalemia typically results from secondary hyperaldosteronism due to sodium depletion; potassium supplements rarely needed once hydration corrected 1
• Hypomagnesemia: Give magnesium oxide 4 mmol capsules (160 mg MgO), 12-24 mmol daily at night when transit is slowest 1
• If oral magnesium fails, add 1-alpha hydroxycholecalciferol 0.25-9.0 mg daily (monitor calcium) or give IV/subcutaneous magnesium sulfate 1

Dietary Management

Foods That Thicken Output

• Marshmallows, bananas, pasta, rice, white bread, mashed potato, and jelly help thicken ileostomy output per American Gastroenterological Association recommendations 2
• Sprinkle extra salt onto meals (0.5-1 teaspoon/day) to prevent dehydration 2
• Consume small, frequent, nutrient-dense meals/snacks 2

Foods to Avoid or Limit

• High fiber foods increase loose stools, flatulence, and bloating 2
• Fruit/vegetable skins, sweetcorn, celery, nuts may cause stoma blockages 2
• Avoid hypotonic and hypertonic drinks as noted above 2

Nutritional Monitoring

• Monitor vitamin B12, fat-soluble vitamins, magnesium, and zinc 2, 4
• Track body weight, BMI, and mid-arm muscle circumference 4

Intravenous Support

For patients unable to maintain hydration despite above measures:

• Subcutaneous saline (0.5-1 L with 4 mmol magnesium sulfate) if needed 1-3 times weekly 1
• Intravenous saline via tunneled central line if more frequent replacement needed; can also deliver parenteral nutrition if undernutrition develops 1
• Avoid fluid overload, which readily causes edema due to elevated aldosterone levels 1

Systematic Approach to High Output (>1.5 L/day)

1. Exclude reversible causes: intra-abdominal sepsis, partial obstruction, enteritis (C. difficile, Salmonella), recurrent disease (Crohn's), medication changes (stopping opiates/steroids, starting prokinetics) 1
2. Implement fluid restriction (<500 mL hypotonic fluids) 1
3. Start glucose-saline solution (≥90 mmol/L sodium) 1
4. Add loperamide 2-8 mg before meals 1
5. For outputs >2-3 L/day: Add PPI or H2 antagonist; consider octreotide if net secretory output 1
6. Correct electrolyte abnormalities in sequence: sodium/water first, then magnesium, then potassium 1
7. Consider IV/subcutaneous support if oral measures insufficient 1

Common Pitfalls

• Encouraging increased oral fluid intake worsens dehydration—hypotonic fluids drive sodium losses that exceed water absorption 1
• Treating hypokalemia before correcting sodium depletion and hypomagnesemia is ineffective 1
• Standard loperamide doses may be inadequate—disrupted enterohepatic circulation requires higher doses 1
• Separating liquids from solids lacks evidence but is commonly advised 1