management of high output stomas

Management of High output Stomas

Muhammad Haris AslamResident, Surgical Unit I

SIMS/Services Hospital, Lahore

Introduction

• It is a surgically created opening, which connects part of a person’s bowel to the outside of their body...

Intestinal fluid flux

• 1.5 L saliva• 2.5 L gastric secretion• 1 L Bile + pancreatic secretions • 3L succus entericus

• Most reabsorbed in Small intestine• 1.5 to 2 L enters colon and it absorbs most of it

and only 200 -400 ml is excreted in stools

• Normal ileostomy output is 1500-1800ml / 24 hours untill adaptation

• After adaptation it is 500- 800 ml/ 24 hours

• If it persists to > 1500 ml/24 hours it is termed as high output stoma

Who is at Risk

• Crohn’s disease patients

• Colectomy

• Vascular accidents

Causes of high output stoma

• Gastric acid Hyper secretion

• Baterial over growth

• Pre stomal ileitis

• Revealed latent disease ( celiac disease, hypolactasia, pancreatic disease, pancreatic insufficiency, thyrotoxicosis)

Causes..cntd..

• Infection ( including clostridium difficile)

• Short bowel

• Adaptation phase

• Uncontrolled inflamation, sepsis and malnutrition

• Lactose in tolerence.

Complications

• Dehydration

• Renal dysfuction including Oxalate stones

• Electrolyte abnormalities

• Malnutrition

• Psychological abnormalities..

Assessment of High output stoma

• Review history.– No. Of bags emptying /night, associated pain etc– Types of fluid , quantity of fluids and food.

• Current medication– Doses of omeprazole– Loperamide– Lactose containing medication

Management

• Step 1• Dietry adjustments

• Isotonic fluids

• Omeprazole

• Megadose loperamide

• Antibiotics for bacterial overgrowth

Step 2

• If output is still >1500ml/ day then

• NPO for 48 hours and IV fluids to assess baselien output

• Review all investigations and management

• Measure daily electrolytes ( including Mg)

• If baseline output is >1200ml/ day then consider long term IV fluids

Step 3

• Is baseline output is < 1200ml/day then• Commence oral rehydration salt trial for 48

hours

Step 4• If output is <1500ml

after isotonics then go to step 6

• If output is > 1500ml after isotonics then start sequentionally– Omeprazole 80mg/day– + loperamide 8mg 4x5/day can

be upto 100mg/day– + codene 60 mg 4xday– +octreotide 3xday– Stop octreotide after 72 hours

if impact is <300 ml/day

Output <1500ml .go to step 5 Output > 1500ml . Plan TPN/ fluids

Step 5

• Commence liquid feed and nutritional suppliments

• Measure effect on output– if < 1500ml go to step 6– If > 1500ml then plan for TPN

Step 6

• Start solid food and measure effect on output

• If > 1500ml then start IV fluids suppliments

How to prevent high output stoma

• Low fibre diet– Reduce the amount of bulk moving through bowel,

helping to rest it

• Add extra salt to meals and increase intake of salty foods

• Not to drink just before, with or 30-60 minutes after meals

• Restrict fluid intake to no more than 1500ml per day– The more you drink, the more will come out of

stoma.

• Smaller more frequent meals may be better tolerated, particularly in the first few weeks.

• Take your time and chew food thoroughly.

• Avoid heavy meals or snacks before bedtime.

• Medications– Loperamide– Codeine Phosphate

Appropriate food

• What to try

• Eat starch and protein– Starch:

• Bread, Cereal, Rice, Pasta, Potatoes

– Proteins: • Meat, Fish, Cheese, Peanut butter, Eggs

• Add extra salt to meals

• Reduce Lactose in diet

• Milk, Ice cream

• Reason

• Slow the movement of food giving more time to digest

• Helps to absorb fluids better

• Decrease bloating and diarrhea

Foods that may decrease stool frequency / diarrhea

• Bananas• Bread – white• Cheese• Oat bran• Oatmeal• Pasta – white

• Peanut butter – smooth• Potatoes• Pretzels• Rice pudding• Rice – white

Foods that may increase stool frequency / diarrhea

• Alcoholic beverages• Beverages that have caffeine

• coffee, tea and cola

• Chocolate• Dried fruit and pineapple• Honey• Jams and Jellies• Juice especially apple, grape

& prune

• Nuts• Olives• Peas,beans &legumes• Pickles• Popcorn• Skins and seeds of fruits &

vegetables• Spicy foods/sauces• Vegetables:

• broccoli, cauliflower & onions

• Whole grains

Appropriate fluids

• Drink 1000ml of an oral rehydration solution / day– ORS– Pedialyte– Home made oral rehydration solution

• Other choices:– Dilute juice (half juice half water)– Tomato juice– Soup

Appropriate fluids

• Limit intake of all other types of fluids (water, tea, coffee and milk) to less than 500 ml per day

• Choose restricted lactose milk

• Avoid drinks high in sugar• juice, regular pop and fruit drinks

Discharge instructions• Avoid sweeteners such as sorbitol and mannitol

• Sugar Free Items

• Sip on oral rehydration fluids throughout the day

• Separate Fluids & Solids

• Wait 30 minutes before & after a meal before drinking fluids

• Limit fluid at meals to less than 125 ml (½ cup)

Discharge instructions

• Measure ileostomy output for 2 days. If over 1200 ml per day, start taking loperamide before meals and at bedtime

• Eat 6-8 small meals per day rather than 3 larger ones

• Limiting fluid intake to 4 ounces with meals

High Output Pouches

Hollister Convatec ColoplastHollister Convatec Coloplast

High Output Pouches

• Decrease frequency of emptying

• At night these can be attached to bedside drainage bag to decrease sleeplessness for patient and caregiver

• Works well for liquid output but needs to be replaced with a standard pouch when output thickens