What is the management plan for a patient with a high output ileocolostomy?

Management of High Output Ileocolostomy

Restrict hypotonic fluids to less than 1000 mL daily and replace remaining fluid requirements with isotonic glucose-saline solution containing at least 90 mmol/L sodium, while initiating antimotility medications and monitoring urine sodium to maintain levels above 20 mmol/L. 1, 2

Definition and Initial Assessment

High output is defined as 1000-2000 mL/24 hours, with outputs exceeding 2000 mL/24 hours placing patients at significant risk for dehydration, electrolyte depletion, and malnutrition. 1, 3

Key monitoring parameters include:

• Daily stoma output measurement 2
• Urine volume (target ≥800 mL/day) 3, 2
• Random urine sodium (target >20 mmol/L) 1, 2
• Serum electrolytes including sodium, potassium, magnesium, and renal function 1, 2
• Body weight trends 3, 2

Acute Management Phase

For newly identified high output or acute decompensation:

• Initiate intravenous normal saline (2-4 L/day) while keeping the patient nil by mouth to demonstrate that output is driven by oral intake 2
• Gradually withdraw IV saline over 2-3 days while simultaneously reintroducing food and restricted oral fluids 2
• Parenteral infusions (fluid and electrolytes) may be needed for ongoing high output stomas 1

Approximately 49% of early high-output stomas (within 3 weeks) resolve spontaneously, but 51% require ongoing medical treatment, particularly when remnant small bowel length is short. 1, 2

Fluid Management Strategy

The cornerstone of management is strategic fluid restriction and replacement:

• Restrict hypotonic fluids (water, tea, coffee, fruit juices, alcohol) to less than 500-1000 mL daily, as these increase sodium losses through the stoma 1, 3, 2
• Avoid hypertonic fluids (commercial soft drinks, concentrated fruit juices, cola) which also cause water and sodium loss 3, 2
• Replace remaining fluid requirements with glucose-saline solution containing ≥90 mmol/L sodium (WHO cholera solution or St. Mark's solution), sipped throughout the day 1, 2

For patients with marginal high output (1-1.5 liters), oral fluid restriction (<1 liter/day) and addition of salt to the diet may be sufficient. 3

Pharmacological Management

Antimotility and antisecretory medications are essential:

• Loperamide is first-line therapy, with doses of 12 mg/day shown to reduce ileostomy output by a median of 16.5% 4
• High-dose loperamide should be considered in patients who fail conventional doses 5
• Proton-pump inhibitors reduce gastric secretions that contribute to increased fecal losses 1
• Additional agents include opium, psyllium fibers, and cholestyramine to reduce intestinal motility or secretions 1
• Oral budesonide has been shown to improve water absorption and decrease stoma output in Crohn's disease patients with ileostomy 1

The large volume of gastric secretion minimizes time for absorption and contributes to increased fecal losses, making acid suppression particularly important. 1

Nutritional Considerations

Bulk-forming agents may slow gastric emptration and improve stool consistency and overall transit time in the small bowel 1

Assess and replace micronutrient deficiencies:

• Vitamin B12 and iron deficiency with replacement therapy as needed 1
• Consider assessment for selenium, zinc, and vitamins A, D, E, and K deficiencies 1

Malabsorption is an important contributing factor to malnutrition, and ongoing high output can result in intestinal insufficiency with unintentional weight loss and nutritional deficiencies. 1

Long-Term Management and Monitoring

Maintenance therapy continues as long as the stoma is present:

• 71% of patients can be weaned from parenteral infusions using oral hypotonic fluid restriction, glucose-saline solution, and anti-diarrheal medication 1, 2
• 8% require continued parenteral or subcutaneous saline in the home setting 1
• Adjustments based on seasonal factors (increased losses in hot weather) 2

Early follow-up after discharge results in significant reduction in readmission rates and allows identification of patients with malnutrition. 1

Interdisciplinary Approach

Multidisciplinary intestinal rehabilitation is essential for successful management:

• Stoma therapists or IBD specialist nurses should be involved as early as possible 1
• Nutritional and clinical assessments must be performed on all patients with high-output stoma 1
• Interdisciplinary team management is best when enterostomy becomes a cause of concern, particularly with nutritional issues 1

Common Pitfalls to Avoid

• Do not allow unrestricted water intake, as hypotonic fluids paradoxically worsen sodium depletion and increase stoma output 1, 3, 2
• Monitor urine sodium closely, as random urinary sodium <20 mmol/L suggests sodium depletion requiring intervention 1, 2
• Avoid delaying parenteral support when oral measures are insufficient, as dehydration can culminate in acute renal failure 1
• Do not underestimate the risk of dehydration, which necessitates hospital admission in up to 17% of patients after colorectal resection with diverting loop ileostomy 1