Makindo Medical Notes.com

These guidelines generally apply to patients with a stoma output of >1.5 l in 24 hours

Introduction

• There are many possible causes of high output stoma including infection and bacterial overgrowth, bowel obstruction, recurrent bowel disease, medicines use.
• Patients require assessment by specialist for assessment and acute treatment. Though corrective measures may “stop" some of the causes, many patients will require on-going treatment for symptom control and to prevent dehydration.
• This guideline is aimed at patients with a stoma output greater than 1000ml, or fistula output greater than 500mls and type 2 or 3 intestinal failure

Step 1a - Assessment

• Ensure full and accurate documentation of fluid balance on fluid balance chart daily – aim for urine output >800ml/24hr or 0.5ml/kg/hour
• Discuss dietary management with patient (see next page)
• Check creatinine, urea and electrolytes (Na⁺ K⁺ Mg²⁺ PO4- Ca²⁺) – correct any abnormalities intravenously (oral supplements often further increase output), check daily throughout all steps
• Check urinary sodium level if hyponatraemia - normal level >20mmol/L
• Review and rationalise any medications which could cause high-output e.g. pro-kinetics, medications known to cause diarrhoea, withdrawal of steroids/opiates, those given with large fluid volumes
• Inform relevant teams - Surgical on-call team immediately via switchboard, stoma nurses and dieticians via

Step 1b - Rehydration and Stabilisation: trial of therapies

• Reduce oral hypotonic fluids to 500ml in 24 hours
• Meet other fluid/electrolyte requirements by intravenous route where possible
• Double strength Dioralyte (i.e. 1 sachet per 100mls) 1L per day. Can be mixed with sugar free cordial to improve taste. 1L contains 40mmol potassium
• Loperamide 2-4mg PO QDS Given 30-60 mins before meals/bed time, capsules can be opened, if short bowel/capsules seen in stoma output consider use of tablets, avoid using liquid
• Lansoprazole 30mg PO OD. Give IV if <50cm small bowel remaining, lansoprazole dispersible tablets 30mg OD can be substituted if swallowing difficulties/enteral feeding tube [Allow 2-3 days to assess efficacy]
• Codeine phosphate 30-60 mg qds 30 minutes before food

Low Magnesium: Can be worsened by PPIs

• Magnesium supplementation as (Magnaspartate®) 10mmol sachets
• Dissolve in 50-200mls of water, tea or orange juice
• One sachet at night, can be increased up to 3 sachets per day (doses above 2 sachets a day are off label)
• Monitor for diarrhoea/gastro-intestinal upset
• Additional IV magnesium may also be required occasionally to maintain levels – secondary care only

STEP 2 - Consider gut rest

• Consider a 24 hour trial of NBM with fluid/electrolyte requirements met fully by intravenous route
• This will help to ascertain if high output is down to fluid intake or net-secretory effect

STEP 3 - Fluid Optimisation

• Start St. Mark’s Solution 1L sipped over 24 hours + allow 1L oral hypotonic fluids - total volume can be adjusted to match fluid requirements in 50:50 ratio (e.g. 1.5L St. Marks : 1.5L hypotonic fluids) [Allow 2-3 days to assess efficacy]

STEP 4 - Medicines Optimisation

• Consider increasing dose of loperamide in steps of 2-4mg PO QDS (max. 24mg QDS) every 2-3 days and give before meals and at bedtime
• Consider trial of codeine 60mg PO QDS (Max. 30mg QDS if GFR<20ml/min)
• Consider trial of octreotide 50-200 micrograms SC TDS (SPECIALIST ADVICE ONLY) Generally only effective for a short period of time owing to development of tolerance to medication
• OTHER MEDICATIONS: Consider use of Artificial Saliva spray as required to help overcome excessive thirst/dry mouth

GOALS OF TREATMENT

• Maintain fluid balance
• Correct electrolyte disturbance
• Maintain stable weight
• Reduce volume of stoma output to manageable level

DIETARY MANAGEMENT

• Encourage a high energy and high protein diet. Encourage low fibre starchy (carbohydrate) foods with every meal e.g. potatoes (avoiding skins), white rice/pasta/bread, low fibre breakfast cereals e.g. rice crispies or cornflakes. Encourage snacks between meals
• Avoid high fibre food e.g. whole grains, beans, pulses, the skins/stalks/seeds of fruits & vegetables, nuts, seeds and porridge Limit oral drinks and advise to sip slowly throughout the day Discourage drinking fluids with meals – aim to leave a gap of 30 minutes before and after meals
• If evidence of persistent hyponatraemia the patient may benefit from adding salt to food and including salty snacks Foods to include to help thicken the output: low fibre carbohydrates (pasta, rice, white bread, potatoes without skins), gelatine containing foods (marshmallows, yoghurt, jelly, fruit gums), eggs, cheese, milk puddings, 1 banana a day
• Foods to avoid which may loosen the output: raw fruit and fresh fruit juice, raw vegetables (includes salad), spicy foods, fried and fatty foods, leafy green vegetables, some sweeteners or foods and sweets that contain sweeteners e.g. Sorbitol, xylitol or mannitol Consider acceptability/tolerability to each patient on an individual basis
• Octreotide is generally only effective for a short period of time owing to development of tolerance to medication. Codeine is generally poorly tolerated/addictive/sedative, so its suitability/efficacy should be reviewed on a regular basis. Can cause rebound increase in output on withdrawal.
• Proton Pump Inhibitors can cause a variety of GI side effects. Long term treatment has been associated with hypomagnesaemia and increased risk of fractures. Hyponatraemia is rare.

ST. MARKS SOLUTION

• 6 teaspoons (20g) glucose powder
• 1 level teaspoon sodium chloride (table salt)
• ½ teaspoon sodium bicarbonate
• 1 litre tap or bottled water
• Mix all the ingredients together and chill in the refrigerator.
• The solution can be flavoured with cordial or squash but it must not be diluted with any more water.
• The solution should be sipped throughout the day.

References

• High output stoma