What is the recommended daily ileostomy output?

Ileostomy Output Management

The goal is to maintain ileostomy output below 1200 ml/day, with outputs exceeding this threshold requiring active intervention to prevent dehydration, electrolyte disturbances, and renal complications. 1

Defining Normal vs. High Output

• Normal ileostomy output ranges from 500-800 ml/day in well-adapted patients 2
• High-output ileostomy is defined as >1200 ml/day, requiring medical management 1, 3
• Outputs of 1200-2000 ml/day typically require oral fluid restriction and glucose-saline solutions 1
• Outputs >2000 ml/day indicate severe high-output stoma requiring aggressive intervention including potential parenteral support 4

Treatment Goals and Monitoring

The primary aims are maintaining hydration/body weight and achieving a daily urine volume of at least 800 ml with sodium concentration >20 mmol/L. 1

Key Monitoring Parameters:

• Daily stoma output volume and consistency 1
• Urine volume and sodium concentration 1
• Body weight and hydration status 1
• Serum electrolytes, particularly magnesium and potassium 1

Stepwise Management Algorithm

Step 1: Exclude Reversible Causes

Before implementing output reduction strategies, rule out:

• Intra-abdominal sepsis or partial bowel obstruction 1, 5
• Enteritis (Clostridium difficile, Salmonella) 1, 3
• Recurrent underlying disease (Crohn's disease, radiation enteritis) 1
• Medication-related causes (sudden steroid/opiate withdrawal, prokinetics) 1

Step 2: Fluid Management (First-Line)

Restrict hypotonic oral fluids to <500 ml/day (water, tea, coffee, fruit juices, alcohol) as these paradoxically increase stomal sodium losses. 1, 5

Replace fluid requirements with glucose-saline solution containing ≥90 mmol/L sodium, sipped throughout the day. 1

Recommended Oral Rehydration Solutions:

• Modified WHO cholera solution: 60 mmol sodium chloride (3.5 g) + 30 mmol sodium bicarbonate (2.5 g) + 110 mmol glucose (20 g) per liter 1
• Alternative solution: 120 mmol sodium chloride (7 g) + 44 mmol glucose (8 g) per liter 1

For outputs 1200-2000 ml/day, patients can often maintain sodium balance with glucose-saline solutions or salt capsules (500 mg, up to 14 capsules/24 hours). 1

Step 3: Antimotility Medications (Second-Line)

Loperamide is the preferred first-line antimotility agent, given 30 minutes before meals. 1, 5, 6

• Standard dosing: 4 mg four times daily 1
• High-dose regimen: 12-24 mg per dose may be needed due to disrupted enterohepatic circulation 1
• Expected effect: 20-30% reduction in water and sodium output 1
• Loperamide is superior to codeine phosphate as it is non-sedating, non-addictive, and doesn't cause fat malabsorption 1

Codeine phosphate 60 mg four times daily can be added if loperamide alone is insufficient. 1, 5

Step 4: Antisecretory Medications (Third-Line)

For outputs >2 liters/day or net secretory states, add gastric acid suppression:

• Omeprazole 40 mg orally once daily (or 40 mg IV twice daily if <50 cm jejunum remains) 1
• Ranitidine 300 mg orally twice daily 1
• Cimetidine 400 mg orally or IV four times daily 1

These agents are as effective as octreotide in reducing stomal output volume without changing macronutrient absorption. 1, 6

Step 5: Octreotide (Fourth-Line)

Octreotide 50 mcg subcutaneously twice daily is reserved for refractory cases, particularly those with net secretory output >3 L/24 hours. 6

• Most effective in patients with secretory-type high output 1, 6
• Can reduce output by 1-2 L/24 hours 6
• Does not improve nutrient absorption and may not eliminate need for parenteral support 1, 6
• Long-term effects on intestinal adaptation are uncertain 6

Step 6: Electrolyte Correction

Hypomagnesemia management (common with high output):

• Initial IV magnesium sulfate, then oral magnesium oxide 4 mmol capsules (160 mg MgO), 12-24 mmol daily, preferably at night 1, 5
• Rehydration to correct secondary hyperaldosteronism is the critical first step 1

Hypokalemia typically resolves with sodium/water repletion and magnesium correction; direct potassium supplementation rarely needed. 1

Step 7: Parenteral Support

For patients failing oral/pharmacologic management, provide:

• Subcutaneous saline (0.5-1 L with 4 mmol magnesium sulfate) if needed 1-3 times weekly 1
• IV saline via tunneled central line if more frequent administration required 1
• Parenteral nutrition if undernutrition develops 1

Special Considerations for Jejunostomy

Jejunostomy outputs are typically higher (sodium content ~90 mmol/L) and require more aggressive fluid/electrolyte management. 1

Patients with <50 cm remaining jejunum often require long-term parenteral support. 1, 4

Critical Pitfalls to Avoid

• Never encourage drinking large volumes of hypotonic fluids to quench thirst—this worsens sodium depletion 1, 5
• Avoid excessive IV fluid administration during rehydration, which causes edema due to elevated aldosterone 1
• Don't overlook hypomagnesemia, which perpetuates hypokalemia and is resistant to potassium replacement alone 1
• Ensure medications are given 30 minutes before meals as output increases postprandially 1, 6
• Crush tablets/capsules if they appear intact in stoma output 1

Outcomes and Prognosis

• Early high-output ileostomy occurs in 16% of cases, with 49% resolving spontaneously and 51% requiring ongoing treatment 4
• Readmission rates for ileostomy-related dehydration approach 31% in some series 7
• Intestinal adaptation occurs over weeks to months, potentially reducing output requirements 2
• Patients with jejunostomy or <200 cm small bowel have the highest risk for persistent high output requiring long-term support 4