Ileostomy Management and Care
Fluid and Electrolyte Management: The Critical Foundation
The single most important intervention for ileostomy patients is restricting hypotonic oral fluids (water, tea, coffee, fruit juices, alcohol) to less than 500 mL daily while replacing fluid requirements with glucose-saline solutions containing at least 90 mmol/L sodium. 1, 2
Fluid Restriction Protocol
- Limit hypotonic fluids to <500 mL/day - this prevents paradoxical worsening of dehydration by reducing sodium losses that exceed water absorption 2
- Avoid hypertonic fluids (fruit juices, Coca-Cola, commercial sip feeds) as these paradoxically increase stomal sodium and water losses 2
- Replace fluid requirements with glucose-saline solution containing ≥90 mmol/L sodium (modified WHO cholera solution/St. Mark's solution: 60 mmol sodium chloride, 30 mmol sodium bicarbonate, 110 mmol glucose per liter) 1, 2
- Patients should consume ≥1 liter of glucose-saline solution daily in small quantities throughout the day; may be chilled or flavored for palatability 2
Hydration Targets
- Daily urine volume ≥800 mL 1, 2
- Urinary sodium concentration >20 mmol/L 1, 2
- Maintenance of body weight 1
Acute Dehydration Management
For patients presenting with marked dehydration:
- Begin with intravenous normal saline (2-4 L/day) while keeping patient nil by mouth 1
- Gradually withdraw IV saline while reintroducing food and restricted oral fluids over 2-3 days 1
- For ongoing needs: subcutaneous saline (0.5-1 L with 4 mmol magnesium sulfate) 1-3 times weekly, or IV saline via tunneled central line if more frequent replacement needed 2
- Avoid fluid overload, which readily causes edema due to elevated aldosterone levels 2
Pharmacologic Management
First-Line Antimotility Therapy
Loperamide is the preferred first-line agent, reducing ileostomy output by 20-30%. 1, 2, 3
- Dose: 2-8 mg taken 30 minutes before meals 1, 2
- Loperamide is FDA-approved for reducing volume of discharge from ileostomies 3
- Superior to codeine phosphate - non-sedative, non-addictive, does not cause fat malabsorption 2
- Due to disrupted enterohepatic circulation in short bowel, high doses (12-24 mg at a time) may be needed 2
Antisecretory Agents
For persistent 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 1, 2
- Octreotide 50 mcg subcutaneously twice daily provides greatest benefit in net secretory outputs (>3 L/day) with sustained long-term effect 2
Dietary Management
Foods That Thicken Output
- Marshmallows, bananas, pasta, rice, white bread, mashed potato, and jelly help thicken ileostomy output 2, 4
- Add extra salt to diet (0.5-1 teaspoon per day) to prevent dehydration 1, 2, 4
- Consume small, frequent, nutrient-dense meals/snacks 2, 4
Foods to Avoid
- High fiber foods increase loose stools, flatulence, and bloating 2, 4
- Fruit/vegetable skins, sweetcorn, celery, nuts may cause stoma blockages 2, 4
High Ostomy Output Management Algorithm
Early High Output (<3 weeks post-surgery, >1.5 L/day)
Prompt evaluation for reversible causes is essential: 5, 2
Exclude infection (postoperative abdominal infection, C. difficile, Salmonella), ileus, medication-related effects (stopping opiates/steroids, starting prokinetics), partial obstruction, recurrent Crohn's disease 5, 2
Hydration is the most important treatment to prevent renal failure - typically requires IV fluids with hospital admission or long-term IV access for home health 5
If HOO persists, early reversal should be considered, although reversal before 6 weeks carries increased complication risk 5
Chronic High Output (>3 weeks post-surgery)
Systematic stepwise approach: 2
- Restrict hypotonic fluids to <500 mL/day 2
- Start glucose-saline solution (≥90 mmol/L sodium) 2
- Add loperamide 2-8 mg before meals 2
- For outputs >2-3 L/day: Add PPI or H2 antagonist 2
- Consider octreotide if net secretory output 2
- Consider IV/subcutaneous support if oral measures insufficient 2
Electrolyte Correction Sequence
Critical principle: Correct sodium and water depletion FIRST before addressing other electrolytes. 1, 2
- Hypokalemia typically results from secondary hyperaldosteronism due to sodium depletion - potassium supplements are rarely needed once sodium/water balance and serum magnesium are corrected 1, 2
- Hypomagnesemia: Give magnesium oxide 4 mmol capsules (160 mg MgO), 12-24 mmol daily at night when transit is slowest 2
- Monitor vitamin B12, fat-soluble vitamins, magnesium, and zinc 2, 4
Ostomy Leakage Prevention and Management
Prevention through preoperative marking by a stomatherapist and meticulous surgical technique is the best strategy. 5
Risk Factors for Leakage
- Obesity, placement within skin crease, loop configuration, liquid effluent, flush stoma 5
Management Steps
- Thicken stool with antidiarrheals to facilitate more solid effluent 5
- Pouching techniques: convex appliance, ostomy belt, paste, or barrier rings to bolster stoma height 5
- Application pearls: Heat appliance with hair dryer before application, lie flat for several minutes after application, ensure peristomal skin is dry, use fine dusting of stomal powder followed by skin sealant 5
- Cut appliance opening one-eighth inch larger than stoma to prevent mucosal irritation while limiting skin exposure to effluent 5
- Measure stoma size at each appliance change for first 8 weeks as size changes 5
Common Pitfalls to Avoid
- Encouraging increased oral fluid intake worsens dehydration - hypotonic fluids drive sodium losses that exceed water absorption 2
- Treating hypokalemia before correcting sodium depletion and hypomagnesemia is ineffective 2
- Standard loperamide doses may be inadequate - disrupted enterohepatic circulation requires higher doses (12-24 mg) 2
- Failing to exclude reversible causes of high output before attributing it solely to the ileostomy 1, 2