What medications and dietary modifications should be prescribed to decrease the output of a high-output ileostomy?

Management of High-Output Ileostomy

The most critical intervention is restricting hypotonic oral fluids (water, tea, coffee, juice) to less than 500 mL daily and replacing fluid requirements with glucose-saline solution containing at least 90-100 mmol/L sodium. 1, 2, 3

Initial Assessment: Rule Out Reversible Causes

Before attributing high output solely to the ileostomy itself, systematically exclude:

• Intra-abdominal sepsis or partial bowel obstruction through clinical examination and imaging 1, 2, 3
• Enteritis (Clostridium, Salmonella) or recurrent inflammatory bowel disease in remaining bowel 1, 2
• Recent medication changes, particularly abrupt discontinuation of steroids or opiates, or initiation of prokinetics like metoclopramide 1, 3

Fluid Management Strategy (Most Important)

This is the cornerstone of management and often the most overlooked intervention:

• Restrict all hypotonic fluids (water, tea, coffee, alcohol, dilute salt solutions) to less than 500 mL daily 1, 2, 3
• Restrict hypertonic fluids (fruit juices, Coca-Cola, most commercial sip feeds containing sorbitol or glucose) to less than 500 mL daily 1
• Replace remaining fluid requirements with glucose-saline solution containing sodium concentration of 90-100 mmol/L 1, 2, 3

Recommended glucose-saline formulation (Modified WHO cholera solution):

• Sodium chloride 60 mmol (3.5 g)
• Sodium bicarbonate 30 mmol (2.5 g)
• Glucose 110 mmol (20 g)
• Tap water to 1 liter 1, 3

Target parameters for adequate hydration:

• Daily urine volume ≥800 mL 1, 2, 3
• Urinary sodium concentration >20 mmol/L 1, 2, 3
• Maintenance of body weight 1, 3

Dietary Modifications

Foods that thicken stoma output (consume liberally):

• Marshmallows, bananas, pasta, rice, white bread, mashed potatoes, jelly 2, 4

Add extra salt to diet:

• 0.5-1 teaspoon per day sprinkled on meals 2, 3, 4

Limit dietary fiber intake:

• High fiber increases loose stools, flatulence, and bloating 2, 4
• Avoid fruit/vegetable skins, sweetcorn, celery, nuts (risk of blockage) 4

Pharmacological Management

First-line: Loperamide (FDA-approved for reducing ileostomy discharge):

• Dose: 2-8 mg taken 30 minutes before meals 1, 2, 3, 5
• Non-sedative and non-addictive 1
• Reduces output by 20-30% 3

Second-line: Add codeine phosphate if loperamide insufficient:

• Dose: 60 mg four times daily 1, 2

For very high output (>2-3 liters/24 hours): Add antisecretory agents:

• Proton pump inhibitors (e.g., omeprazole 40 mg once daily) or H2 antagonists 1, 2
• Can reduce output by 1-2 liters/24 hours 1, 3
• Consider octreotide if unable to absorb oral medications 1

Additional agents to consider:

• Bulk-forming agents (psyllium fibers) may slow gastric emptying 1
• Cholestyramine if bile salt malabsorption suspected 1

Electrolyte Correction Sequence

Critical principle: Always correct sodium and water depletion FIRST before addressing other electrolytes. 1, 3

For marked dehydration:

• Begin with intravenous normal saline 2-4 L/day while keeping patient nil by mouth for 24-48 hours 1, 3
• Gradually withdraw IV saline over 2-3 days while reintroducing food and restricted oral fluids 1, 3
• Avoid fluid overload (high aldosterone levels increase edema risk) 1

Hypokalemia management:

• Most commonly due to sodium depletion with secondary hyperaldosteronism 1, 3
• Potassium supplements rarely needed once sodium/water balance corrected 1, 3
• Also check magnesium (hypomagnesemia causes refractory hypokalemia) 1

Hypomagnesemia correction:

• Intravenous magnesium sulfate initially, then oral magnesium oxide 1, 2
• Magnesium oxide 4 mmol (160 mg) capsules, 12-24 mmol daily, preferably at night 2

Monitoring Parameters

Daily monitoring:

• Stoma output volume and consistency 2
• Urine volume and urinary sodium concentration 2
• Body weight and hydration status 2

Laboratory monitoring:

• Serum urea, creatinine, sodium, potassium, magnesium 1, 2
• Random urinary sodium <20 mmol/L suggests sodium depletion 1
• Vitamin B12 and iron levels (long-term management) 1, 2
• Consider selenium, zinc, vitamins A, D, E, K 1

Common Pitfalls

The most common mistake is encouraging patients to drink hypotonic fluids to quench thirst, which paradoxically causes massive stomal sodium losses and worsens dehydration. 1 Patients must understand that drinking plain water when they have high ileostomy output will make them more dehydrated, not less.