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Peristomal skin breakdown: Mechanical breakdown (from adhesives, cleaning agents), exposure to effluent fluids (eg, from poorly fitting appliances), or allergic reaction to pouch Parastomal hernia formation: Especially common among colostomies.5,6 Risk factors include obesity, poor abdominal muscle tone, and chronic cough Peristomal infection, abscess or fistula formation: Relatively uncommon in early dpostoperative perio. Reported incidence of these complications is 2% to 14.8%7 Stomal stenosis: Narrowing of the stoma, which might need surgical revision Stomal necrosis: Occurs perioperatively as a result of venous congestion or arterial insufficiency from a tight fascial opening. The incidence of early stomal necrosis is reported to range from 2.3% to 17%
See discussions, stats, and author profiles for this publication at: https://www.researchgate.net/publication/259171519 An Overview of Ostomies and the High-Output Ostomy Article in Hospital Medicine Clinics · October 2013 DOI: 10.1016/j.ehmc.2013.06.001 CITATIONS READS 471 2 authors, including: Bilal Gondal The University of Chicago M… 27 PUBLICATIONS 79 CITATIONS SEE PROFILE Available from: Bilal Gondal Retrieved on: 20 September 2016 An Overview of Ostomies and the High-Output Ostomy Bilal Gondal, MD, MRCSI, Meghna C Trivedi, MD* KEYWORDS Stoma output Ileostomy Colostomy Management of stomas Nutrition support High-output stoma HOSPITAL MEDICINE CLINICS CHECKLIST A high-output stoma (HOS) is defined as greater than L of output from the stoma in a 24-hour period Jejunostomy is a HOS Jejunum ranges in length from 200 to 300 cm, and greater than 90% of nutrient absorption occurs in first 100 to 150 cm of the intestines Clinical assessment of a patient with HOS focuses on identifying and correcting fluid and electrolyte disturbances, and optimizing nutritional status It is a common mistake to encourage patients with a HOS to drink large amounts of hypotonic fluids Use Oral Rehydration Solution or other “isotonic” solutions for fluid replacement Greater than 50 cm of functioning bowel is required for absorption of an oral proton-pump inhibitor Dietary modifications play an important role in decreasing the stomal output Correction of sodium and water depletion, oral or intravenous supplementation of magnesium, and vitamin D analogue have been used to correct hypomagnesemia, which is a problematic complication of HOS A multidisciplinary team approach is vital to enhance the quality of life of patients with an ostomy DEFINITIONS What is a stoma and what are the different types of stomas? An ostomy is a surgically made opening from the inside of an organ to the outside.1 Stomas may be temporary or permanent Temporary stomas are usually reversed at Department of Medicine, UMass Memorial Medical Center, 119 Belmont Street, Worcester, MA 01605, USA * Corresponding author E-mail address: Meghna.Trivedi@umassmemorial.org Hosp Med Clin (2013) e542–e551 http://dx.doi.org/10.1016/j.ehmc.2013.06.001 2211-5943/13/$ – see front matter Ó 2013 Elsevier Inc All rights reserved High-Output Ostomy a later date, allowing the blind loop of intestine to be used once again and, more importantly, eliminating the need for an ostomy, allowing the patient to defecate normally Types: Gastrostomy and jejunostomy: openings between the abdominal wall and stomach or jejunum, respectively These openings are used predominantly for enteral feeding tubes Ileostomy: opening from the small intestine to the abdominal wall so that feces bypass the large intestine and the anal canal Colostomy: opening from the large intestine to the abdominal wall so that feces bypass the anal canal Urostomy: connection between the urinary tract and abdominal wall leading to a “urinary conduit” so urine passes straight into a stoma bag and thus bypasses the urethra What is the typical ostomy output/stool output in different types of resections? Jejunostomy: A jejunostomy is a high-output fecal stoma and can have up to L/d of stomal output The jejunum is a major organ for nutrient absorption (most fats, proteins, vitamins, and carbohydrates not already absorbed in the stomach and duodenum).2 It is important to emphasize to patients that they should limit the oral intake of fluids or a vicious cycle may begin A jejunostomy tube placed for feeding should be clamped when not in use, not left to drain Ileostomy: Initially 1200 mL/d which then decreases to about 600 mL/d During the early postoperative period and episodes of gastroenteritis, daily output can be 1800 mL or even higher.3 Colostomy: 200 to 600 mL/d (Table 1) What is a high-output stoma? Normally in a healthy adult, about L of intestinal secretions (0.5 L saliva, L gastric acid, and 1.5 L pancreaticobiliary secretions) are produced in response to food and Table Characteristics of different types of ostomies Type of Ostomy Location Type of Discharge Patient Problems Ileostomy Right lower quadrant Liquid or paste like Continuous drainage Contains digestive enzymes Skin protection Odorous Dehydration Food blockage Ascending colostomy Middle or right upper abdomen Liquid or semisolid Contains digestive enzymes Skin protection Odorous Dehydration Gas control Transverse colostomy Center of abdomen, higher side Semisolid Frequent drainage May contain digestive enzymes Skin protection Odorous Gas control Descending colostomy or sigmoid colostomy Left lower quadrant Normal stool Odorous Skin protection Odorous Gas control Adapted from Hollister, Inc Types of ostomies Libertyville (IL): 1992 e543 e544 Gondal & Trivedi drink each day.4 A high-output stoma (HOS) is defined as greater than L (8 cups) of fluid from the ostomy in a 24-hour period STOMA COMPLICATIONS Peristomal skin breakdown: Mechanical breakdown (from adhesives, cleaning agents), exposure to effluent fluids (eg, from poorly fitting appliances), or allergic reaction to pouch Parastomal hernia formation: Especially common among colostomies.5,6 Risk factors include obesity, poor abdominal muscle tone, and chronic cough Peristomal infection, abscess or fistula formation: Relatively uncommon in early postoperative period Reported incidence of these complications is 2% to 14.8%7 Stomal stenosis: Narrowing of the stoma, which might need surgical revision Stomal necrosis: Occurs perioperatively as a result of venous congestion or arterial insufficiency from a tight fascial opening The incidence of early stomal necrosis is reported to range from 2.3% to 17%7 Retraction: Occurs commonly with obesity or weight gain after surgery Stomal prolapse: Occurs with elevated intra-abdominal pressures, more common in transverse loop colostomies and end colostomies CAUSES OF HIGH-OUTPUT STOMA Intra-abdominal sepsis Surgery leaving less than 200 cm residual small bowel and no remaining colon Obstruction in intestine at stoma site or proximal Infection of the intestine (eg, Clostridium difficile) Methicillin-resistant Staphylococcus aureus enteritis is also reported to cause a high stoma output in the early postoperative period after bowel surgery8 Active Crohn disease Radiation enteritis Withdrawal of medications, such as steroids or opiates Administration of certain prokinetic medications (eg, metoclopramide, erythromycin, or laxatives) Metformin has also been shown to cause increased stomal output9 HISTORY AND EXAMINATION What are the features of a healthy stoma? The stoma is located above the skin level, and is red and moist (pallor can suggest anemia, whereas a dark hue may indicate ischemia) Immediately postoperatively, it looks swollen The swelling subsides within weeks Patients need to be reassured that a red stoma is a healthy stoma The patient should not report pain or other discomfort associated with the intestinal stoma, as there are no somatic nerve endings in bowel There is no separation between the mucocutaneous edge and the skin There is no erythema, ulceration, rash, or inflammation in the surrounding skin What are signs and symptoms seen in patients with HOS? Patients with HOS present with watery stool and report emptying the stomal pouch/appliance more than to 10 times per day The output may be difficult High-Output Ostomy to contain and may cause leakage Patients may complain of dry mouth, increased thirst, fatigue, light-headedness, shortness of breath, muscle cramps, or abdominal cramping It is important to evaluate these patients for signs of dehydration and electrolyte disturbances Hyponatremia, hypokalemia, and hypomagnesemia are commonly noted in these patients.10 Dehydration can lead to renal failure HOS puts patients at risk of malnutrition Patients complain of feeling fatigued or dizzy; they may have unintentional weight loss, impaired wound healing (due to protein-energy malnutrition and inadequate micronutrients), and easy bruisability (due to vitamin deficiency or malabsorption) What are the psychological effects of having a stoma? Anxiety and depression are commonly seen; ostomies may contribute to perceived reduced quality of life It is crucial to prepare patients undergoing stoma formation with educational materials and one-on-one counseling with a mental health specialist Introducing patients to other patients who already live with an ostomy may also be valuable The first few weeks post stoma are the most vital Patients frequently have difficulty managing their stoma while performing daily activities (eg, shopping), and changing bags without necessary facilities Patients may experience a change in body image, and intimate relationships may suffer.11,12 “Phantom rectum” may occur during the first weeks after a colostomy or ileostomy, whereby patients may experience sudden urges to defecate In this case the patient may require reassurance and support, as this can be very distressing MANAGEMENT Which adults with HOS should be hospitalized? Patients with moderate to severe dehydration and renal failure need hospitalization These patients are kept NPO (nothing by mouth) and are hydrated with 0.9% saline (2–4 L/d) After to days of intravenous hydration, food and restricted fluids up to 500 mL are introduced while slowly weaning intravenous fluids.13 Strict input and output should be recorded Urine output should measure at least 800 mL/d with a sodium concentration greater than 20 mmol/L Weight should be followed daily Serum electrolytes and renal function should be measured on a regular basis Electrolytes should be repleted appropriately It is important to identify the cause of HOS and to treat the underlying cause as early as possible What are the goals of management? The important principles on which management of high-output stoma should be based are as follows: Correct dehydration and electrolyte imbalance Reduce stoma output by pharmacologic and nonpharmacologic methods Identify and treat the underlying cause of HOS Act as quickly as possible to prevent complications Patients should be linked with a nutrition counselor who has experience in managing these complex patients A multidisciplinary approach to management of HOS should e545 e546 Gondal & Trivedi be undertaken It should include the patient and his or her family, a nutritionist, the patient’s surgeon, and potentially other health care providers What pharmacologic strategies can be used in patients with high-output stoma? A conservative approach is used initially If it fails to improve the patient’s clinical condition, medications to decrease the amount of stool output are used The most commonly used medications are proton-pump inhibitors and antidiarrheal medications such as loperamide (Imodium) and diphenoxylate/atropine (Lomotil) a Proton-pump inhibitors Proton-pump inhibitors work by covalently binding to the H1K1-ATPase system at the secretory surface of gastric parietal cells This action suppresses the final step in gastric acid production, and leads to inhibition of both basal and stimulated acid secretion Gastric hypersecretion may occur in the first weeks after bowel resection, but may also occur over a longer period of time.14 In the immediate postoperative period, it has been recommended to use a pantoprazole drip (80 mg bolus followed by mg/h).15 Once oral intake is started, proton-pump inhibitors are used orally Omeprazole, 20 mg twice a day, may be used to reduce hypersecretion.16 It is important to bear in mind that greater than 50 cm of functioning jejunum is required for absorption of oral proton-pump inhibitors.17 b Loperamide (Imodium) Loperamide slows transit time, resulting in decreased intestinal output Loperamide can be used in patients with HOS to reduce bowel movements to to times per day The patient should be advised to take 2–4 mg of loperamide 30 minutes before meals and at bedtime The patient should be advised not to exceed mg/d (over-the-counter dose) and 16 mg/d (prescription dose).15 c Diphenoxylate-atropine (Lomotil) If loperamide is not effective, codeine phosphate or diphenoxylate-atropine may be used Diphenoxylate-atropine has a relaxation effect on intestinal smooth muscles and thereby reduces intestinal output by 20% to 30%.18–20 Diphenoxylate has central opiate effects and an increased risk of overdose It is chemically related to some narcotics, and may be habit forming if taken in quantities larger than prescribed Atropine may cause anticholinergic side effects Diphenoxylate-atropine is available as 4-mg tablets, and the recommended dose is tablets times per day.17 If any tablets/capsules emerge unchanged in stool/stomal output, tablets/ capsules can be crushed, opened, and/or mixed with water or put on food Liquid formulations are also available d Codeine phosphate and tincture of opium are used if loperamide and diphenoxylate-atropine are not effective e Somatostatin/octreotide Octreotide is a synthetic analogue of hormone somatostatin Octreotide decreases intestinal output by mechanisms: It inhibits the release of gastrointestinal hormones, namely gastrin, cholecystokinin, secretin, motilin, and other hormones This inhibition decreases the secretion of water, bicarbonate, and pancreatic enzymes into the intestine, thus decreasing the intestinal volume.21 Octreotide relaxes the intestinal smooth muscles, thereby allowing for an increased intestinal capacity It increases intestinal water and electrolyte absorption.22 High-Output Ostomy Octreotide is dosed 50 to 250 mg subcutaneously to times per day It may be needed if there is insufficient length of remaining jejunum (