Table 1 Treatment protocol for high output stomas
From: Protocol for the detection and nutritional management of high-output stomas
Detection and treatment of the underlying cause | |
|---|---|
Before initiating pharmacological and nutritional treatment, the underlying cause of the HOS must be detected and treated: | |
• Gastrointestinal infections (after tissue culture assay to rule outClostridium difficileinfection) | |
• Related to the medication: | |
• Prokinetic indicated drugs: metoclopramide, laxatives, erythromycin, etc. | |
• Abrupt withdrawal of corticosteroids | |
• Metformin also provokes increased stoma output | |
• Bowel obstructions | |
• Intra-abdominal sepsis | |
• Inflammatory bowel disease | |
• Short bowel syndrome | |
Stage I: Initial treatment: reduction of fluid and electrolyte loss | ▪ Restrict fluid intake to 500–1000 ml/day. Isotonic drinks are the best option. Avoid the intake of hypotonic drinks, tea, coffee, alcohol and fruit juices. |
▪ Perform intravenous hydration. | |
▪ Prescribe loperamide 2 mg before breakfast-lunch-dinner and at night. | |
▪ Monitoring: strict fluid balance, check body weight daily, perform complete blood analysis including electrolytes (magnesium, calcium, phosphorus, potassium and sodium). | |
• Start oral or I/V supplementation of electrolytes if necessary, according to analysis results. | |
▪ Start nutritional assessment and treatment (see below). | |
▪ Determine B12 levels in patients who are NOT recently operated on. | |
▪ Determine stoma output at 48–72 h: if it is resolved, increase oral fluid intake and start serum therapy and the withdrawal of medication. | |
Stage II: If HOS continues, perform follow up treatment | ▪ Continue the fluid intake restriction and the nutritional monitoring. Start SueroOral intake (2.5 g NaCl, 1.5 g KCl, 2.5 g HCO3Na, 1.5 g sugar and 1 L water) as the only oral source of fluids (500–1000 ml/day). |
▪ Increase loperamide dose to 4 mg before breakfast-lunch-dinner and at night (maximum 16 mg/day). | |
▪ Start treatment with omeprazole 20 mg/day. If already prescribed, increase to 40 mg/day. | |
▪ If fat malabsorption, steatorrhoea, or pruritic bilious output is present, add cholestyramine 4 g/12 before breakfast and dinner. | |
▪ Continue monitoring and electrolyte supplementation if necessary, as in Stage I. | |
▪ If HOS persists after 48–72 h, initiate Stage III. | |
Stage III. If HOS persists, evaluate treatment and case management | ▪ Supplement with hydro- and lipid-soluble oral vitamins. |
▪ Maintain loperamide and add codeine 15–60 mg. before breakfast-lunch-dinner. Contraindicated if the patient has CrCl <15 ml/min. | |
▪ If fat malabsorption persists, increase cholestyramine dose to 4 g before breakfast-lunch-dinner. | |
▪ If HOS > 2000 ml after two weeks: add octreotide 200 mcg/day for 3–5 days. If no improvement is obtained, suspend this treatment. | |
▪ Monitor fluid intake. | |
Specific nutritional treatment | |
▪ Avoid fluid intake during meals. | |
▪ It may be advisable to temporarily increase the salt content of foods in order to promote fluid reabsorption. | |
▪ Little is known about the use of soluble fibre. Insoluble fibre is contraindicated because of the risk of bowel obstruction. | |
▪ The effect of antidiarrhoeal microorganisms on HOS is unknown. | |