What are the management and treatment options for a patient with an ostomy that is only producing bile?

Management of Bile-Only Ostomy Output

An ostomy producing only bile indicates a very proximal jejunostomy or high-output fistula, requiring immediate aggressive fluid and electrolyte resuscitation with intravenous normal saline while restricting oral hypotonic fluids to prevent life-threatening dehydration and renal failure. 1

Immediate Assessment and Stabilization

Fluid Resuscitation

• Initiate intravenous normal saline at 2-4 liters daily while keeping the patient nil by mouth to demonstrate that output is driven by oral intake 1
• Monitor for adequate hydration by targeting daily urine volume of at least 800 ml with urinary sodium concentration greater than 20 mmol/l 1
• Exercise caution to avoid fluid overload, which readily causes edema due to high circulating aldosterone levels in these patients 1
• Over 2-3 days, gradually withdraw intravenous saline while carefully reintroducing food and restricted oral fluids 1

Exclude Reversible Causes

• Evaluate for intra-abdominal sepsis, partial or intermittent bowel obstruction, infectious enteritis (Clostridioides difficile, Salmonella), recurrent Crohn's disease, or radiation enteritis 1
• Review medications for recent discontinuation of steroids or opiates, or initiation of prokinetics like metoclopramide 1
• Consider structural problems including stomal stricture, intestinal obstruction, ileus, or enteric fistula 1

Oral Fluid Management Strategy

Strict Fluid Restriction

• Restrict all hypotonic oral fluids (water, tea, coffee, fruit juices, alcohol, dilute salt solutions) to less than 500 ml daily 1
• Also restrict hypertonic fluids (fruit juices, Coca-Cola, most commercial sip feeds containing sorbitol or glucose) to less than 500 ml daily, as these cause stomal losses of water and sodium 1
• This restriction is critical because hypotonic fluids cause large stomal sodium losses, worsening dehydration despite the patient's thirst 1

Glucose-Saline Replacement Solution

• Provide modified WHO cholera rehydration solution with sodium concentration of at least 90 mmol/l, as jejunal effluent sodium content is approximately 90 mmol/l 1
• Standard formulation: 60 mmol (3.5 g) sodium chloride + 30 mmol (2.5 g) sodium bicarbonate + 110 mmol (20 g) glucose per liter of tap water 1
• Alternative formulation: 120 mmol (7 g) sodium chloride + 44 mmol (8 g) glucose per liter of tap water 1
• Encourage sipping one liter or more throughout the day in small quantities 1
• Chill or flavor with fruit juice to improve palatability 1

Pharmacological Management

Antisecretory Agents

• Proton pump inhibitors (omeprazole) can be absorbed in the duodenum/upper jejunum and reduce gastric secretions 1
• Note that if less than 50 cm of jejunum remains, drug absorption problems are likely and intravenous administration may be needed 1

Antimotility Agents

• Loperamide requires higher doses than usual because the disrupted enterohepatic circulation prevents normal recirculation 1
• Consider codeine phosphate 30-60 mg taken 30 minutes before food if loperamide is insufficient 2
• Octreotide 500 μg subcutaneously three times daily can be used for refractory cases, reducing gastric, biliary, and pancreatic secretions 2

Electrolyte Management

Sodium and Water Balance

• Correct sodium/water depletion before attempting to treat other electrolyte abnormalities 1
• Monitor serum sodium, potassium, and magnesium levels closely 2
• Target urinary sodium >20 mmol/l to confirm adequate sodium status 2

Potassium and Magnesium

• Hypokalaemia correction requires first correcting sodium/water depletion and bringing serum magnesium into normal range 1
• Potassium supplements are uncommonly needed once sodium and magnesium are corrected 1
• Magnesium depletion is common and requires replacement 2

Nutritional Considerations

Dietary Modifications

• High carbohydrate diet emphasizing polysaccharides (starch) rather than simple sugars 2
• Normal fat intake, though medium chain triglycerides may be better absorbed 1
• Avoid simple sugars and monosaccharides to prevent D-lactic acidosis 2
• Limit coffee, alcohol, and spices which worsen output 2

Monitoring for Complications

• Watch for D-lactic acidosis: confusion with metabolic acidosis and large anion gap in patients consuming high simple carbohydrate diet 1, 2
• Treatment involves restricting mono/oligosaccharides, encouraging polysaccharides, thiamine supplements, and broad-spectrum antibiotics 1
• Monitor for hyperammonemia (confusion, elevated blood ammonia), which can be corrected with arginine supplementation 1
• Assess for thiamine deficiency, which can cause Wernicke-Korsakoff psychosis and responds rapidly to large doses of thiamine 1

Long-Term Management Considerations

Surgical Options

• If high output persists despite maximal medical management, early reversal of the stoma should be considered 1
• Reversal before 6 weeks of index surgery carries increased complication risk, requiring careful risk-benefit assessment 1

Monitoring Parameters

• Daily weight and urine output 1
• Serum electrolytes including sodium, potassium, magnesium 2
• Urinary sodium concentration 1, 2
• Assess for micronutrient deficiencies including vitamin B12, fat-soluble vitamins, magnesium, and zinc 3

Critical Pitfalls to Avoid

• Never encourage drinking hypotonic fluids to quench thirst—this is the most common mistake and worsens sodium depletion 1
• Do not administer excessive intravenous fluids, which cause edema due to high aldosterone levels 1
• Do not attempt to correct potassium before correcting sodium/water depletion and magnesium 1
• Avoid simple sugars in the diet, which can precipitate D-lactic acidosis in patients with remaining colon 1, 2