This document discusses the management of high output stomas. It begins by defining a high output stoma as an ileostomy with an output of over 1500 ml/24 hours. It then lists potential causes and risks for developing a high output stoma. A 6 step process is outlined for assessing and managing high output, beginning with dietary adjustments and medications and progressing to IV fluids and nutrition if needed. Discharge instructions focus on appropriate diet, fluid intake, and use of anti-diarrheal medications. Special high output pouches are also mentioned.

1. Management of High output
Stomas
Muhammad Haris Aslam
Resident, Surgical Unit I
SIMS/Services Hospital, Lahore

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

3. 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

4. • 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

5. Who is at Risk
• Crohn’s disease patients
• Colectomy
• Vascular accidents

6. 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)

7. Causes..cntd..
• Infection ( including clostridium difficile)
• Short bowel
• Adaptation phase
• Uncontrolled inflamation, sepsis and malnutrition
• Lactose in tolerence.

8. Complications
• Dehydration
• Renal dysfuction including Oxalate stones
• Electrolyte abnormalities
• Malnutrition
• Psychological abnormalities..

9. 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

10. Management
• Step 1
• Dietry adjustments
• Isotonic fluids
• Omeprazole
• Megadose loperamide
• Antibiotics for bacterial overgrowth

11. 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

12. Step 3
• Is baseline output is < 1200ml/day then
• Commence oral rehydration salt trial for 48
hours

13. 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

14. Step 5
• Commence liquid feed and nutritional
suppliments
• Measure effect on output
– if < 1500ml go to step 6
– If > 1500ml then plan for TPN

15. Step 6
• Start solid food and measure effect on output
• If > 1500ml then start IV fluids suppliments

16. 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

17. • 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.

18. • Avoid heavy meals or snacks before bedtime.
• Medications
– Loperamide
– Codeine Phosphate

19. 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

20. 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

21. 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

22. 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

23. 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

24. 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)

25. 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

26. High Output Pouches
Hollister Convatec Coloplast
Hollister Convatec Coloplast

27. 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