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Management of high output stomas

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This presentation gives general overview of management of high output stoma.

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Management of high output stomas

  1. 1. Management of High output Stomas Muhammad Haris Aslam Resident, Surgical Unit I SIMS/Services Hospital, Lahore
  2. 2. Introduction • It is a surgically created opening, which connects part of a person’s bowel to the outside of their body...
  3. 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. 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. 5. Who is at Risk • Crohn’s disease patients • Colectomy • Vascular accidents
  6. 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. 7. Causes..cntd.. • Infection ( including clostridium difficile) • Short bowel • Adaptation phase • Uncontrolled inflamation, sepsis and malnutrition • Lactose in tolerence.
  8. 8. Complications • Dehydration • Renal dysfuction including Oxalate stones • Electrolyte abnormalities • Malnutrition • Psychological abnormalities..
  9. 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. 10. Management • Step 1 • Dietry adjustments • Isotonic fluids • Omeprazole • Megadose loperamide • Antibiotics for bacterial overgrowth
  11. 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. 12. Step 3 • Is baseline output is < 1200ml/day then • Commence oral rehydration salt trial for 48 hours
  13. 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. 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. 15. Step 6 • Start solid food and measure effect on output • If > 1500ml then start IV fluids suppliments
  16. 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. 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. 18. • Avoid heavy meals or snacks before bedtime. • Medications – Loperamide – Codeine Phosphate
  19. 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. 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. 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. 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. 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. 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. 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. 26. High Output Pouches Hollister Convatec Coloplast Hollister Convatec Coloplast
  27. 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

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