Top 5 Things to tell Patients with High Output Ileostomies

Did you know that there are approximately 130,000 ileostomies done per year?

More surprising is that 16-50% of these can be classified as “high output”. The largest obstacle that these patients face is dehydration. Dehydration can lead to acute kidney injury, increase odds of chronic kidney disease and hospital readmissions. High output ileostomies can be defined as output greater than 1500 ml per day.

How Can We Keep Patients from Dehydration and Hospital Readmission?

Finding what works for each patient is individualized. Many times, patients are told to “drink more” which can increase ostomy losses. If they drink less, their ostomy output decreases but so does their urine output.

Recommendations:

1. Find the “sweet spot” of how much a person can drink without increasing ostomy output. This may take several weeks after ostomy creation. Often times, patients will need supplemental IV fluids until that amount is found.
2. Try Oral Rehydration Solutions. These should be there go-to beverage. These may not reduce output from the ileostomy but does increase the amount of absorption. Avoid fluids that are hypotonic such as water, tea and coffee, Hypotonic solutions pull sodium into the small bowel to increase the osmolarity. Hypotonic solutions are the lesser of the evils when compared to hypertonic solutions. Avoid hypertonic solutions such as juices, ice cream and sweetened oral nutrition supplements. These pull water into the small bowel and increase output. I have included a handout on homemade oral rehydration solutions below.
3. Be aware of medications that can increase output. There are many liquid medications that contain sorbitol, mannitol and xylitol, all which contribute to diarrhea and output. These can include the liquid forms of furosemide, metoclopramide, prevacid, simethicone and many more.
4. Enlist anti-diarrheal agents to slow motility. Some institutions have specific guidelines for these medications and when and how to escalate them. Steps including starting with proton pump inhibitors and then adding loperamide. If output does not decrease, increase the amounts every 48 hours until output is less than 1500 ml in 24 hours. This could take up to almost 3 weeks and can include escalating to diphenhydramine and codeine. Please see table 4 of this article for more information on this. (https://practicalgastro.com/2022/03/11/high-output-ileostomies-preventing-acute-kidney-injury/#:~:text=NUTRITION%20ISSUES%20IN,XLVI%2C%20Issue%202)
5. Educate the patient! Anyone with a high output ileostomy should be measuring their intake and their 24 hour ostomy output AND urine output. The urinary output is the most important. The goal for urinary output is > 1200 ml per day. The goal for ileostomy output is <1200-1500 ml per day. If a patient is prone to kidney stone formation, the goal of intake should be 2400 ml of fluid per day.

In summary

Ileostomy patients vary in their output. Recommendations should be patient specific. Remember, the body will always try to adapt and normalize as the patient progresses, so what the out

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