High output Ileostomies

 

• Output >1.5 -2.0 L/24 hours leading dehydration & dys-electrolytemia.
• Occurs in 31% of small bowel stomas.
• Daily output increases with increasing small bowel resection
• Resection of 15-50cm of terminal ileum results in an increase of >300 g/24hr vs with <15cm removed 
• Mature ileostomy put out up to 1200mL/day
• Jejunostomies can put out up to 6 L/day
• Colostomies usually only put out 200-600mL/day 
  
  
  

Normal intestinal fluid transport

• 9 -10 L of fluid passes the ligament of Treitz/ day
• Jejunum absorbs ~ 6 L & Ileum ~ 2.5 L
• Colon absorbs rest but 100 mL excreted in feces daily.

Ostomy at ileocecal valve expected to produce 1-1.5 L of stool output/day

Containing approximately

• 200 mEq of sodium
• 100 mEq of chloride &
• 10 mEq of potassium
  
  
  

In Extensive ileal resection, >100 cm, bile salts loss outpaces hepatic production, leading to bile acid deficiency & steatorrhea

Hypomagnesemia occurs in 78% with a jejunostomy.

Common complications include:

• - Dehydration & AKI
• - Low serum sodium
• - Low urinary sodium
• - Low serum magnesium
• - Loss of Chloride & bicarbonate leading to metabolic acidosis
• - High plasma renin & aldosterone
• - Weight loss / malnutrition
• - Low Vitamin B12 (if > 60-100cm of terminal ileum resected)
  
  
  

Management:

Rehydrate & replace electrolytes

Oral hypotonic fluid is restricted & a glucose-saline solution is sipped.

Medication

• To slow transit (Imodium/Lomotil/opioids) or
• To reduce secretions (omeprazole for gastric acid)
• Octreotide/sandostatin
  
  
  
• GLP-2, enhances gut adaptation, inhibits gastric acid secretion & slow emptying; stimulates intestinal blood flow; increases intestinal barrier function; & enhances nutrient & fluid absorption.