An overview of ostomies and the high out

Peristomal skin breakdown: Mechanical breakdown (from adhesives, cleaning agents), exposure to effluent fluids (eg, from poorly fitting appliances), or allergic reaction to pouch
Parastomal hernia formation: Especially common among colostomies.5,6 Risk factors include obesity, poor abdominal muscle tone, and chronic cough
Peristomal infection, abscess or fistula formation: Relatively uncommon in early dpostoperative perio. Reported incidence of these complications is 2% to 14.8%7
Stomal stenosis: Narrowing of the stoma, which might need surgical revision
Stomal necrosis: Occurs perioperatively as a result of venous congestion or arterial insufficiency from a tight fascial opening. The incidence of early stomal necrosis is reported to range from 2.3% to 17%

An Overview of Ostomies and the High-Output Ostomy

Article in Hospital Medicine Clinics · October 2013

DOI: 10.1016/j.ehmc.2013.06.001

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Available from: Bilal Gondal Retrieved on: 20 September 2016

A n O v e r v i e w o f O s t o m i e s a n d t h e

H i g h - O u t p u t O s t o m y

Bilal Gondal,MD, MRCSI, Meghna C Trivedi, MD*

HOSPITAL MEDICINE CLINICS CHECKLIST

1 A high-output stoma (HOS) is defined as greater than 2 L of output from the stoma in a 24-hour period

2 Jejunostomy is a HOS Jejunum ranges in length from 200 to 300 cm, and greater than 90% of nutrient absorption occurs in first 100 to 150 cm of the intestines

3 Clinical assessment of a patient with HOS focuses on identifying and correcting fluid and electrolyte disturbances, and optimizing nutritional status

4 It is a common mistake to encourage patients with a HOS to drink large amounts of hypotonic fluids Use Oral Rehydration Solution or other “isotonic” solutions for fluid replacement

5 Greater than 50 cm of functioning bowel is required for absorption of an oral proton-pump inhibitor

6 Dietary modifications play an important role in decreasing the stomal output

7 Correction of sodium and water depletion, oral or intravenous supplementation

of magnesium, and vitamin D analogue have been used to correct hypomagne-semia, which is a problematic complication of HOS

8 A multidisciplinary team approach is vital to enhance the quality of life of patients with an ostomy

DEFINITIONS

1 What is a stoma and what are the different types of stomas?

An ostomy is a surgically made opening from the inside of an organ to the outside.1

Stomas may be temporary or permanent Temporary stomas are usually reversed at

Department of Medicine, UMass Memorial Medical Center, 119 Belmont Street, Worcester, MA

01605, USA

* Corresponding author.

E-mail address: Meghna.Trivedi@umassmemorial.org

KEYWORDS

 Stoma output  Ileostomy  Colostomy  Management of stomas  Nutrition support

 High-output stoma

Hosp Med Clin 2 (2013) e542–e551

http://dx.doi.org/10.1016/j.ehmc.2013.06.001

2211-5943/13/$ – see front matter Ó 2013 Elsevier Inc All rights reserved.

a later date, allowing the blind loop of intestine to be used once again and, more

impor-tantly, eliminating the need for an ostomy, allowing the patient to defecate normally

Types:

 Gastrostomy and jejunostomy: openings between the abdominal wall and

stom-ach or jejunum, respectively These openings are used predominantly for enteral

feeding tubes

 Ileostomy: opening from the small intestine to the abdominal wall so that feces

bypass the large intestine and the anal canal

 Colostomy: opening from the large intestine to the abdominal wall so that feces

bypass the anal canal

 Urostomy: connection between the urinary tract and abdominal wall leading to a

“urinary conduit” so urine passes straight into a stoma bag and thus bypasses

the urethra

2 What is the typical ostomy output/stool output in different types of resections?

 Jejunostomy: A jejunostomy is a high-output fecal stoma and can have up to

6 L/d of stomal output The jejunum is a major organ for nutrient absorption

(most fats, proteins, vitamins, and carbohydrates not already absorbed in the

stomach and duodenum).2It is important to emphasize to patients that they

should limit the oral intake of fluids or a vicious cycle may begin A jejunostomy

tube placed for feeding should be clamped when not in use, not left to drain

 Ileostomy: Initially 1200 mL/d which then decreases to about 600 mL/d During

the early postoperative period and episodes of gastroenteritis, daily output can

be 1800 mL or even higher.3

 Colostomy: 200 to 600 mL/d (Table 1)

3 What is a high-output stoma?

Normally in a healthy adult, about 4 L of intestinal secretions (0.5 L saliva, 2 L gastric

acid, and 1.5 L pancreaticobiliary secretions) are produced in response to food and

Table 1

Characteristics of different types of ostomies

Type of Ostomy Location Type of Discharge Patient Problems

Ileostomy Right lower

quadrant

Liquid or paste like Continuous drainage Contains digestive enzymes

Skin protection Odorous Dehydration Food blockage Ascending colostomy Middle or right

upper abdomen

Liquid or semisolid Contains digestive enzymes

Skin protection Odorous Dehydration Gas control Transverse colostomy Center of abdomen,

higher side

Semisolid Frequent drainage May contain digestive enzymes

Skin protection Odorous Gas control Descending colostomy

or sigmoid colostomy

Left lower quadrant Normal stool

Odorous

Skin protection Odorous Gas control Adapted from Hollister, Inc Types of ostomies Libertyville (IL): 1992.

drink each day.4A high-output stoma (HOS) is defined as greater than 2 L (8 cups) of fluid from the ostomy in a 24-hour period

STOMA COMPLICATIONS

 Peristomal skin breakdown: Mechanical breakdown (from adhesives, cleaning agents), exposure to effluent fluids (eg, from poorly fitting appliances), or allergic reaction to pouch

 Parastomal hernia formation: Especially common among colostomies.5,6Risk factors include obesity, poor abdominal muscle tone, and chronic cough

 Peristomal infection, abscess or fistula formation: Relatively uncommon in early postoperative period Reported incidence of these complications is 2% to 14.8%7

 Stomal stenosis: Narrowing of the stoma, which might need surgical revision

 Stomal necrosis: Occurs perioperatively as a result of venous congestion or arterial insufficiency from a tight fascial opening The incidence of early stomal necrosis is reported to range from 2.3% to 17%7

 Retraction: Occurs commonly with obesity or weight gain after surgery

 Stomal prolapse: Occurs with elevated intra-abdominal pressures, more com-mon in transverse loop colostomies and end colostomies

CAUSES OF HIGH-OUTPUT STOMA

 Intra-abdominal sepsis

 Surgery leaving less than 200 cm residual small bowel and no remaining colon

 Obstruction in intestine at stoma site or proximal

 Infection of the intestine (eg, Clostridium difficile) Methicillin-resistant Staphylo-coccus aureus enteritis is also reported to cause a high stoma output in the early

postoperative period after bowel surgery8

 Active Crohn disease

 Radiation enteritis

 Withdrawal of medications, such as steroids or opiates

 Administration of certain prokinetic medications (eg, metoclopramide, erythro-mycin, or laxatives) Metformin has also been shown to cause increased stomal output9

HISTORY AND EXAMINATION

1 What are the features of a healthy stoma?

 The stoma is located above the skin level, and is red and moist (pallor can sug-gest anemia, whereas a dark hue may indicate ischemia) Immediately postoper-atively, it looks swollen The swelling subsides within 6 weeks Patients need to

be reassured that a red stoma is a healthy stoma The patient should not report pain or other discomfort associated with the intestinal stoma, as there are no somatic nerve endings in bowel

 There is no separation between the mucocutaneous edge and the skin

 There is no erythema, ulceration, rash, or inflammation in the surrounding skin

2 What are signs and symptoms seen in patients with HOS?

 Patients with HOS present with watery stool and report emptying the stomal pouch/appliance more than 8 to 10 times per day The output may be difficult Gondal & Trivedi

e544

to contain and may cause leakage Patients may complain of dry mouth,

increased thirst, fatigue, light-headedness, shortness of breath, muscle cramps,

or abdominal cramping It is important to evaluate these patients for signs of

dehydration and electrolyte disturbances Hyponatremia, hypokalemia, and

hy-pomagnesemia are commonly noted in these patients.10Dehydration can lead

to renal failure

 HOS puts patients at risk of malnutrition Patients complain of feeling fatigued or

dizzy; they may have unintentional weight loss, impaired wound healing (due to

protein-energy malnutrition and inadequate micronutrients), and easy bruisability

(due to vitamin deficiency or malabsorption)

3 What are the psychological effects of having a stoma?

Anxiety and depression are commonly seen; ostomies may contribute to perceived

reduced quality of life It is crucial to prepare patients undergoing stoma formation

with educational materials and one-on-one counseling with a mental health specialist

Introducing patients to other patients who already live with an ostomy may also be

valuable The first few weeks post stoma are the most vital Patients frequently have

difficulty managing their stoma while performing daily activities (eg, shopping), and

changing bags without necessary facilities Patients may experience a change in

body image, and intimate relationships may suffer.11,12

“Phantom rectum” may occur during the first weeks after a colostomy or ileostomy,

whereby patients may experience sudden urges to defecate In this case the patient

may require reassurance and support, as this can be very distressing

MANAGEMENT

1 Which adults with HOS should be hospitalized?

Patients with moderate to severe dehydration and renal failure need hospitalization

These patients are kept NPO (nothing by mouth) and are hydrated with 0.9% saline

(2–4 L/d) After 2 to 3 days of intravenous hydration, food and restricted fluids up to

500 mL are introduced while slowly weaning intravenous fluids.13 Strict input and

output should be recorded Urine output should measure at least 800 mL/d with a

sodium concentration greater than 20 mmol/L

Weight should be followed daily Serum electrolytes and renal function should be

measured on a regular basis Electrolytes should be repleted appropriately It is

important to identify the cause of HOS and to treat the underlying cause as early as

possible

2 What are the goals of management?

The 4 important principles on which management of high-output stoma should be

based are as follows:

 Correct dehydration and electrolyte imbalance

 Reduce stoma output by pharmacologic and nonpharmacologic methods

 Identify and treat the underlying cause of HOS

 Act as quickly as possible to prevent complications

Patients should be linked with a nutrition counselor who has experience in managing

these complex patients A multidisciplinary approach to management of HOS should

be undertaken It should include the patient and his or her family, a nutritionist, the patient’s surgeon, and potentially other health care providers

3 What pharmacologic strategies can be used in patients with high-output stoma?

A conservative approach is used initially If it fails to improve the patient’s clinical condition, medications to decrease the amount of stool output are used The most commonly used medications are proton-pump inhibitors and antidiarrheal medications such as loperamide (Imodium) and diphenoxylate/atropine (Lomotil)

a Proton-pump inhibitors

Proton-pump inhibitors work by covalently binding to the H1K1-ATPase system

at the secretory surface of gastric parietal cells This action suppresses the final step in gastric acid production, and leads to inhibition of both basal and stimulated acid secretion

Gastric hypersecretion may occur in the first 2 weeks after bowel resection, but may also occur over a longer period of time.14 In the immediate postoperative period, it has been recommended to use a pantoprazole drip (80 mg bolus followed

by 8 mg/h).15Once oral intake is started, proton-pump inhibitors are used orally Omeprazole, 20 mg twice a day, may be used to reduce hypersecretion.16 It is important to bear in mind that greater than 50 cm of functioning jejunum is required for absorption of oral proton-pump inhibitors.17

b Loperamide (Imodium)

Loperamide slows transit time, resulting in decreased intestinal output Lopera-mide can be used in patients with HOS to reduce bowel movements to 1 to 3 times per day The patient should be advised to take 2–4 mg of loperamide 30 minutes before meals and at bedtime The patient should be advised not to exceed

8 mg/d (over-the-counter dose) and 16 mg/d (prescription dose).15

c Diphenoxylate-atropine (Lomotil)

If loperamide is not effective, codeine phosphate or diphenoxylate-atropine may

be used Diphenoxylate-atropine has a relaxation effect on intestinal smooth mus-cles and thereby reduces intestinal output by 20% to 30%.18–20 Diphenoxylate has central opiate effects and an increased risk of overdose It is chemically related

to some narcotics, and may be habit forming if taken in quantities larger than pre-scribed Atropine may cause anticholinergic side effects Diphenoxylate-atropine

is available as 4-mg tablets, and the recommended dose is 2 tablets 4 times per day.17If any tablets/capsules emerge unchanged in stool/stomal output, tablets/ capsules can be crushed, opened, and/or mixed with water or put on food Liquid formulations are also available

d Codeine phosphate and tincture of opium are used if loperamide and diphenoxylate-atropine are not effective

e Somatostatin/octreotide

Octreotide is a synthetic analogue of hormone somatostatin

Octreotide decreases intestinal output by 3 mechanisms:

 It inhibits the release of gastrointestinal hormones, namely gastrin, cholecysto-kinin, secretin, motilin, and other hormones This inhibition decreases the secre-tion of water, bicarbonate, and pancreatic enzymes into the intestine, thus decreasing the intestinal volume.21

 Octreotide relaxes the intestinal smooth muscles, thereby allowing for an increased intestinal capacity

 It increases intestinal water and electrolyte absorption.22

Gondal & Trivedi

e546

 Octreotide is dosed 50 to 250 mg subcutaneously 3 to 4 times per day It may be

needed if there is insufficient length of remaining jejunum (<50 cm) to absorb a

proton-pump inhibitor in patients with jejunostomy

 SMS 201-995 is a very potent analogue of somatostatin that has been shown to

decrease proximal ileostomy output.23

f Clonidine

Clonidine has been shown to reduce intestinal output in patients with HOS or

short bowel syndrome with high output refractory to treatment with antidiarrheals

and antisecretory agents Clonidine has been shown to significantly reduce output,

thus limiting the need for parenteral nutrition and intravenous fluids The

recom-mended dose is 0.1 to 0.3 mg up to 3 times per day.24

g Steroids/fludrocortisone:

Oral fludricortisone, high-dose hydrocortisone, or intravenous aldosterone each

has been shown to occasionally reduce stomal output in patients with functioning

ileum Fludricortisone increases ileal sodium absorption.25,26

4 What nonpharmacologic strategies should be used in patients when they initially

experience increasing volume output of their stoma?

 The patient should be instructed to avoid drinking hypotonic fluids and

bever-ages such as tea, coffee, alcohol, and fruit juices, and avoid foods containing

high amounts of sugar

 Oral input and stomal output should be monitored closely Adequate urine output

(0.5 mL/kg/h) should be maintained

 Oral Rehydration Solution (ORS) is recommended to prevent dehydration The

World Health Organization recommended ORS consists of 3.5 g sodium chloride,

2.5 g sodium bicarbonate, 1.5 g potassium chloride, and 20 g of mixture in 1 L of

potable water This drink can be easily prepared by mixing 8 teaspoons of sugar,

1 teaspoon of salt, and 1 cup of orange juice in 1 L of drinking water Patients are

encouraged to sip at least 1 L of this solution at frequent intervals

 Alternative such as Pedialyte, Rehydralyte, and Ceralyte are good hydration

solutions for patients with a HOS

 Gatorade G2 with one-eighth teaspoon of salt added to every 8 ounces of the

drink is another good alternative to ORS

 Patients should eat small meals every 2 to 3 hours or 6 to 8 times a day for better

digestion and absorption, and include foods that may help thicken stools The list

of foods is provided in the next section

 Starch and protein-rich food slow the transit time, thus providing the body more

time for digestion

 Reducing lactose in the diet helps to decrease bloating and diarrhea

 Salt should be used liberally

 High-fiber food and food with skins and roughage that may increase output

should be avoided

5 Which foods decrease the amount of diarrhea/ostomy output?

 In general, complex carbohydrates should be consumed, as they slow down the

transit time through the intestine and provide bulk to the stool Foods that are rich

in complex carbohydrates are pasta (white), bread (white), grains, rice (white),

potatoes, fruits (apples, bananas), and vegetables without skin

 Foods such as tapioca pudding, creamy peanut butter, almond butter, potatoes

(without skin), oatmeal, and apple sauce help thicken foods and limit the stomal

output

6 Which foods increase the amount of diarrhea/ostomy output?

 Simple carbohydrates such as honey, sugar, corn syrup, soda, chocolates, jams, jellies, and so forth increase the amount of water in intestines secondary to osmotic effect, and increase the amount of ostomy output

 Sugar-free products containing sorbitol, mannitol, or xylitol should be avoided,

as they can worsen diarrhea

 Beverages containing caffeine, such as coffee, tea, cola, and alcohol, are stim-ulants that increase stool output

 Juices, especially apple, grape, and prune juice, are high in sugar and cause diarrhea

 Juices with pulp, dried fruits such as raisins and pineapple, frozen berries, and coconut should be avoided

 Raw vegetables, corn, popcorn, potato skins, stir-fried vegetables, peas, beans, legumes, and salads should be avoided during the period of high ostomy output,

as they are high in fiber and increase the stool output (Table 2)

7 How should hypomagnesemia be managed?

Magnesium depletion is an important electrolyte derangement in patients with jejunos-tomy Sodium depletion causes secondary hyperaldosteronism, thereby affecting magnesium balance Patients may become symptomatic with a serum magnesium level of less than 0.6 mmol/L Patients may suffer from fatigue, muscle weakness, dizziness, nausea, vomiting, and muscle cramps

Water and sodium depletion should be corrected to correct hypomagnesemia Oral magnesium in the form of magnesium oxide is used as gelatin capsules of 4 mmol to a total of 12 to 24 mmol/d.13It does not appear to increase stomal output Magnesium oxide is usually taken at night when transit time is slowest and can be maximally absorbed

If oral magnesium oxide fails to increase magnesium to optimal levels, 1a-hydrox-ycholecalciferol in increasing doses can be used Oral 1a-hydrox1a-hydrox-ycholecalciferol

Table 2

Dietary recommendations for patients with ostomy

Eat meals in small amounts frequently, every

2 or 3 h or 6–8 times a day

Prevents bloating Helps digestion and absorption Helps meet nutritional needs Include foods in diet that thickens stool Helps decrease stool output

Include starchy foods like white rice, white

pasta, bread, cereal, and potatoes

Include protein foods including fish, meat,

eggs, cheese, and peanut butter

These foods slow the movement of food through intestines, giving the body more time for digestion

Include salty snacks like crackers, chips,

pretzels

Helps absorb fluids better Reduce lactose in diet Reduces bloating and diarrhea

Avoid high-fiber diet like whole grains and

food with membranes

Reduces bloating and diarrhea, helps decrease stool output

Avoid foods high in sugar like jams, jellies,

honey, white and brown sugar, molasses

Reduces diarrhea/stool output Gondal & Trivedi

e548

increases intestinal and renal absorption of magnesium The dose of 0.25 to 9 mg daily

is gradually increased (every 2–4 weeks in 0.25-mg increments) while ensuring that

hypercalcemia does not occur.27Magnesium can also be administered in intravenous

infusions with saline

PERFORMANCE IMPROVEMENT

There is no specific performance improvement measure related to management of

HOS However, several practices may be associated with improved outcomes:

 A multidisciplinary approach to the management of patients with stoma is very

important in enhancing the patient’s quality of life This multidisciplinary team

includes the colorectal surgeon, wound ostomy continence nurse, nutritionist,

patient, and family members involved in the care of the patient

 Use of ORS instead of hypotonic fluids when the patient becomes dehydrated

 Early intervention or hospitalization when the patient develops high output and

signs/symptoms of dehydration

 Concurrent attention to the psychological needs of the patient with an ostomy

The United Ostomy Association of America (UOAA) is a national organization that

provides support, information, and advocacy to patients with ostomy and their

care-givers The UOAA is a member of the International Ostomy Association The UOAA

Web site is a useful online resource for patients with ostomy, with discussion boards,

support groups, and general information for patients

CLINICAL GUIDELINES

Nightingale J, Woodward JM Guidelines for the management of patients with a short

bowel; on behalf of the Small Bowel and Nutrition Committee of the British Society of

Gastroenterology Published in Gut Available athttp://dx.doi.org/10.1136/gut.2006

091108

FUTURE DIRECTIONS

Four randomized placebo-controlled trials have been performed using growth

hor-mone to stimulate mucosal growth for better absorption of nutrients.28–30In 3 studies

there was no significant increase in nutrient absorption, but 1 did show a small

improvement in nutrient absorption.31

GLP-2 has been shown to cause villus growth Plasma levels of GLP-2 are low in

patients with jejunostomy.32GLP-2 is given as subcutaneous injections, and a small

increase in nutrient absorption has been shown.33

Intestinal transplantations are possible in patients with “intestinal failure,” and more

than 1200 such surgeries have been performed worldwide Intestinal transplant has

not yet been recommended as an alternative therapy for patients with intestinal failure

who have been safely maintained on long-term intravenous nutrition, which is partly

due to the excellent outcomes reported for long-term parenteral nutrition and the

com-plications and challenges posed by intestinal transplant.34

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2 Bryant RA Anatomy and physiology of the gastrointestinal tract In: Colwell JC,

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principles St Louis (MO): Mosby; 2004 p 33–62

3 McCann E Routine assessment of the patient with an ostomy In: Milne C, Corbett I, Dubuc D, editors Wound, ostomy, and continence nursing secrets Philadelphia: Hanley and Belfus; 2003 p 299–305

4 Tsao SK, Baker M, Nightingale JM High-output stoma after small-bowel resec-tions for Crohn’s disease Nat Clin Pract Gastroenterol Hepatol 2005;2:604–8

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11 Brown H, Randle J Living with a stoma: a review of the literature J Clin Nurs 2005;14(1):74–81

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14 Windsor CW, Fejfar J, Woodward DA Gastric secretion after massive small bowel resection Gut 1969;10(10):779–86

15 Jeejeebhoy KN Short bowel syndrome: a nutritional and medical approach CMAJ 2002;166:1297–302

16 Kusunoki M, Shoji Y, Okamoto T, et al Treatment of high output enterocutaneous fis-tulas with a somatostatin analogue and famotidine Eur J Surg 1992;158(8):443–5

17 Parrish CR The clinician’s guide to short bowel syndrome Pract Gastro 2005; 29(9):67 Available at: http://www.practicalgastro.com/getArticles.php?yr52005

&mon59&maxYr52013

18 Newton CR Effect of codeine phosphate, Lomotil and Isogel on ileostomy func-tion Gut 1978;19:377–83, 94

19 King RF, Norton T, Hill GL A double-blind crossover study of the effect of loper-amide hydrochloride and codeine phosphate on ileostomy output Aust N Z J Surg 1982;52:121–4, 95

20 Tytgat GN, Huibregtse K Loperamide and ileostomy output-placebo-controlled double-blind crossover study Br Med J 1975;2:667–8

21 Spiliotis J, Tambasis E, Christopoulou A, et al Sandostatin as hormonal tempo-rary protective ileostomy Hepatogastroenterology 2003;50(53):1367–9

22 Sancho JJ, di Costanzo J, Nubiola P, et al Randomized double-blind placebo-controlled trial of early octreotide in patients with postoperative enterocutaneous fistula Br J Surg 1995;82(5):638–41

23 Kusuhara K, Kusunoki M, Okamoto T, et al Reduction of the effluent volume in high-output ileostomy patients by a somatostatin analogue, SMS 201-995 Int J Colorectal Dis 1992;7:202–5

24 McDoniel K, Taylor B, Huey W, et al Use of clonidine to decrease intestinal fluid losses in patients with high-output short-bowel syndrome JPEN J Parenter Enteral Nutr 2004;28(4):265–8

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