clostridium difficile, colostomy, diarrhoea, fluid therapy, high output, ileostomy, magnesium, stoma
The incidence of stoma formation (colostomy, ileostomy, jejunostomy) in the western world for the adult population is 2-4 per 1000 population with colorectal cancer being the most common (65%) indicator for this procedure.
30 % patients with a new stoma experience high output (HOS) defined as more than 1500 ml output in 24 hours on two consecutive days. In the first couple of days post stoma formation output is expected to be somewhat high due to the bowel adapting to the new changes, however, this situation resolves rapidly. Output exceeding 3000 ml in 24 hrs is classed as excessive output stoma (EOS).
Causes of high output from a stoma are
- Infection 43%
- Prokinetic agents (drugs) 14%
- Unknown 43%
HOS is classified even further as early onset (EHOS) and late onset (LHOS).
Early High Output Stoma
16% stoma patient experience early high output stoma (EHOS) on average occurring around Day 8 post-operatively. EHOS is defined clinically as more than 1500ml per 24 hours on at least two consecutive days within three weeks of stoma formation usually occurring before discharge from hospital.
Late High Output Stoma
The prevalence of late high output stoma (LHOS) is 14% occurring on average around Day 25. The development of HOS occurring more than three weeks post stoma formation is classed as LHOS.
Unfortunately, studies have found that as many as 28% of stoma patients are readmitted to hospital with significant weight loss (5-7 kgs).
23-43% of these readmissions are due to HOS with evidence of electrolyte imbalance and dehydration. Electrolyte imbalance is of significant concern. Magnesium, Potassium and Calcium are particularly affected in this clinical scenario.
- Hypomagnesaemia – low levels of Magnesium is common in stoma patients due to the decreased absorption surface area of the bowel. Magnesium is a key component of many chemical reactions inside the cells of the body which are required for muscle and nerve activity, maintenance of normal heart beat and a healthy immune system.
- Hypokalaemia – low potassium levels are also common however treatment is less than effective until Magnesium levels are normalised first. Early signs of hypokalaemia are general weakness, muscle cramps and numbness and tingling usually experienced in the lower extremities first.
- Hypocalcaemia – As per above, treatment for low calcium is less than effective until the Magnesium levels are within normal range.
The first line of treatment for stomas with high output is to diagnose and treat the underlying cause before commencing nutritional and pharmacological intervention.
Clostridium Difficile is seen in an increasing number of hospitalised patients experiencing diarrhoea and HOS patients should be screened to rule out this as a cause of their high stoma output. Studies suggest this agent is associated with 3-10 per 1000 general hospitalisations.
Medications which have been found to increase the risk for high output are as per below, and consideration should be given to ceasing and or replace with alternative drugs.
- Prokinetic (maxalon, laxatives, erythromycin)
- Cortico-steroid abrupt withdrawal
Bowel Obstruction is another quite serious possible cause for high outputs as is Short Gut Syndrome (intestines fail to absorb enough nutrition and or fluids in and occurs in normal length bowel or shorter bowel due to surgery).
Suggested protocol by Arenas Villafranca et al. describes a 3 stage approach to the treatment of stomas with high output.
Initial treatment includes
- restricting oral fluid intake to 500-1000 ml per day avoiding hypotonic fluids i.e., tea, coffee, alcohol, fruit juices
- administering IV replacement therapy
- prescribing of Loperamide 2mgs before each meal and at night is recommended
- daily weighs and strict fluid balance and
- monitoring of blood analysis is necessary and treat imbalances as necessary.
If stoma output has resolved in 2-3 days then increase oral fluid intake, withdraw medication and start serum therapy (injection of serum containing antibodies to the disease specifically being treated)
If high output continues Stage II treatment recommendation is to
- continue with restricting oral fluids
- increase Loperamide and commence omeprazole
- If fats, pus or undigested food/medications are present suggestive of malabsorption, steatorrhea or pruritic bilious output add cholestyramine to the medication regime
If the high output persists, a further 2-3 day’s – Stage III is initiated. Stage III includes
- supplementation with hydro and lipid soluble oral vitamins
- maintain loperamide
- add codeine (only if >15ml/min creatinine clearance)
- increase cholestyramine if malabsorption continues
- after two weeks if HOS >2000mls add octreotide for 3-5 days if no improvement suspend this treatment.
A success rate of 100% was achieved in Arenas Villafranca et al. study with use of the early examination and treatment protocol as described above.
Given such results consideration for a standardised protocol for the treatment and management of high output stomas, should be formalised.
Jose J Arenas Villafranca, Cristobal López-Rodríguez, Jimena Abilés, Robin Rivera, Norberto Gándara Adán and Pilar Utrilla Navarro 2015 Protocol for the detection and nutritional management of high-output stomas Nutrition Journal 14:45 DOI 10.1186/s12937-015-0034-z
Kwiatt M, Kawata M, 2013, Avoidance and Management of Stomal Complications, Clin Colon Rectal Surg 2013;26:112–121. DOI http://dx.doi.org/ 10.1055/s-0033-1348050. ISSN 1531-0043.
Rostami K, Al Dulaimi D. 2015 Elemental diets role in treatment of High ileostomy output and other gastrointestinal disorders, Gastroenterol Hepatol Bed Bench 2015;8(1):71-76).