Management of High Output Ileostomy

Initial Assessment

• Determine the remaining length of bowel through contrast studies to help predict outcomes and guide nutritional support 1
• Examine stoma output characteristics to assess severity 1
• Exclude other causes of high output, including intra-abdominal sepsis 2, enteritis 1, recurrent disease in remaining bowel 2, and sudden discontinuation of medications 1
• Monitor fluid output and urine sodium to guide fluid management 4

Fluid Management

• Initially administer intravenous normal saline with the patient kept nil by mouth to demonstrate output is driven by oral intake 1
• Restrict oral hypotonic fluids to less than 500 ml daily 1, 2
• Encourage drinking glucose-saline replacement solution with sodium concentration of at least 90 mmol/L 1, 2
• Use modified WHO cholera rehydration solution or alternative rehydration solution with higher sodium concentration 1, 3

Medication Management

• Administer loperamide 2-8 mg before meals to reduce motility and stoma output 2
• Consider adding codeine phosphate if loperamide alone is insufficient 2
• Use drugs that reduce gastric acid secretion for secretory output 2
• Correct hypokalaemia by addressing sodium/water depletion and normalizing serum magnesium 1, 3

Nutritional Considerations

• Maintain adequate nutrition while managing fluid balance 4
• Add salt to diet to the limit of palatability 1
• Consider adding sodium chloride to liquid feeds to achieve sodium concentration near 100 mmol/L 2

Monitoring Parameters

• Aim for daily urine volume of at least 800 ml with sodium concentration >20 mmol/L 1
• Monitor hydration status, body weight, and electrolytes regularly 1, 4

Common Pitfalls to Avoid

• Avoid encouraging patients to drink hypotonic solutions to quench thirst, which paradoxically increases stomal sodium losses 1, 2
• Correct magnesium deficiency to prevent hypokalemia 5
• Avoid administering excessive intravenous fluids, which can cause edema 1

Long-term Management

• Combine oral fluid restriction with increased dietary salt for patients with marginally high stoma outputs 1
• Consider continued parenteral or subcutaneous saline in the home setting for patients with ongoing high output 4
• Implement multidisciplinary intestinal rehabilitation for successful long-term management 4