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High output stoma. Richard Johnston 06/09/13. Case of:. High output ileostomy Jejunostomy. Elective Small Bowel resection. Baseline. Recently. 39 yrs old lady 6yr history of recurrent stricturing CD Right hemi 5yr ago no cigs BO 3*/day 5-ASA B12 nil else. Obstructive episodes

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high output stoma

High output stoma

Richard Johnston

06/09/13

case of
Case of:
  • High output ileostomy
  • Jejunostomy
elective small bowel resection
Elective Small Bowel resection

Baseline

Recently

39 yrs old lady

6yr history of recurrent stricturing CD

Right hemi 5yr ago

no cigs

BO 3*/day

5-ASA

B12

nil else

Obstructive episodes

2 * 5-10cm distal SB strictures

Weight loss of 7kg from 66kg

BMI 23

No oedema

laparotomy
Laparotomy

Findings

Procedure

extensive distal small bowel disease with a walled off perforation around the neo-terminal ileum

Adhesions++

abscess and distal small bowel was fully removed en masse with no drains inserted

Primary anastomosis was not made

colon remained in situ

end ileostomy formed.

remaining small bowel was assessed to be healthy and ~ 3.5 m in length.

day 5 post op
Day 5 post-op

Clinical assessment

Stoma volume 3 litres/day

sepsis/obstruction No clinical evidence

24 hours urinary volume 800 ml

iv fluids nil

Oedema nil

Eating little

Drinking 2.5 litres of squash/water/tea

renal biochemistry normal

day 5 post op what to do
Day 5 post-opWhat to do?

Clinical assessment

Stoma volume 3 litres/day

sepsis/obstruction No clinical evidence

24 hours urinary volume 800 ml

iv fluids nil

Oedema nil

Eating little

Drinking 2.5 litres of squash/water/tea

renal biochemistry normal

early high output ileostomy
Early high output Ileostomy
  • >2l/day
  • Present in 20% of ileostomies
  • Normally no cause found, and resolves in >50%
  • Mortality ~ 8% (sepsis)
  • Aetiology:

Obstructed

Sepsis – intra-abdominal

Enteric disease: Inflammation/infection - C Diff

Medication

Short bowel: Jejunostomy

Nightingale et al. Colorectal Disease 2009

losses depend where it comes from
Losses depend where it comes from

NICE 2013

Page 40 of 189

losses depend where it comes from1
Losses depend where it comes from

NICE 2013

Page 40 of 189

small bowel stoma electrolytes
Small bowel stoma + electrolytes
  • Under-replaced salt and water losses

Rising urea and creatinine

Low sodium – serum or urine

Secondary hyperaldosteronism: low magnesium and potassium

Low Potassium = dehydrated (assuming > 50cm jejunum)

  • NOT phosphate – if low then pt refeeding
dangers of sodium and fluid xs
Dangers of sodium and fluid XS
  • Our ancestors faced dehydration
  • Nature has developed many strategies to overcome sodium and water deficiency
  • No methods to excrete XS sodium or water
  • So no defence mechanism to abnormal saline
fluid and electrolyte balance
Fluid and electrolyte balance

Clinical

Lab

Fluid balance charts

Weights

Oedema

30ml/hr

Urinary sodium <20mmol/L: secretor/ retainer

Plasma urea and creatinine (catabolic state, low protein intake and reduced muscle mass)

Sodium low

Magnesium and potassium low

oral hypertonic fluids
Oral hypertonic fluids
  • Can avoid iv fluids in ¾ patients and nutrition support in 2/3
  • 500-1000ml hypotonic fluids/day

Nightingale et al. 2009

supportive medical management for a high output stoma
Supportive medical management for a high output stoma
  • Start

PPI – gastric hypersecretion, no change in macronutrient absorption

Loperamide (?syrup) – enterohepatic circulation

Codeine

Octreotide – reduces high output stoma losses but no benefit on energy/nitrogen balance and may induce fat malabsorption. Expensive and painful

NB: Loperamide and codeine CI in obstruction

  • Stop NSAIDs, laxatives, prokinetics
  • Screen C diff
case continued
Case continued...

Urinary Na 7 mmol/L

2L Hartmann’s

Daily fluids:

500 ml oral hypotonic fluids

1 litre hypertonic glucose–saline

increase oral food intake

loperamide 8mg qds

omeprazole 40 mg bd

Stomal losses 1-1.5L/day

Mobile

what can she eat with her new ilesostomy
What can she eat with her new ilesostomy?
  • What she likes

vs.

  • Low residue
day 9
Day 9

Fevers, vomiting and RIF tenderness

CT – collection and obstruction

Laparotomy – adhesions and internal fistulae

Surgical drain and stoma re-fashioned at 140cm

HDU

Iv antibiotics

what are the
What are the

Issues?

Solutions ?

what are the1
What are the

Issues

Solutions

Sepsis

PEM

140cm SB

what are the2
What are the

Issues

Solutions

Sepsis

PEM

140cm SB

Antibiotics and drain

EN / PN

.....

intestinal failure
Intestinal failure

‘inabilityto maintainprotein-energy, fluid, electrolyte or micronutrient balance

from either obstruction, dysmotility, surgical resection, congenital defect or

disease associated loss of absorption’.

Sub classified into three types:

  • Type 1 Self-limiting.

E.g. ileus, IF is temporary and often predictable

support fluid, electrolytes +/- nutrition with PN

  • Type 2 Intestinal failure in severely ill patients

Major bowel resection or a septic patient with metabolic or nutritional complications.

Most overcome their initial acute illness with only a few develop type 3 IF

  • Type 3 Chronic intestinal failure requiring long term nutritional support

Chronic intestinal failure even after resolution of the acute illness and intestinal adaptation.

assessment
Assessment

Sepsis

Nutritional status – energy, protein, electrolytes

Anatomy

Plan

Edema (fluid balance)

Drugs

  • S
  • N
  • A
  • P
  • E
  • D
s sepsis
S sepsis
  • may not be classical, can get C diff in SB
  • Low threshold for CT
  • Culture lines
s sepsis in this pt
S sepsis in this pt
  • We have a cunning plan of antibiotics and drain
n nutritional status clinical assessment
N nutritional statusclinical assessment

Macronutrient

Micronutrient

MUST

Recent intakes

Weight loss signs

Anthropometry

Current dry weight

urea and creatinine

Albumin

Low K, Phos, Mg predict refeeding risk

No role for a ‘full nutrient profile’

the case
The case...
  • Day 10 post admission with little orally during admission and pre-ceding PEM
  • Handgrip - weak
  • No oedema but further 2kg wt loss
  • Low urea and creat
  • Normal K, Mg and PO4
  • Albumin .......
a anatomy
A anatomy

Jejuno-colon

Jejunostomy

  • Adaptation via peptide YY
  • No adaptation
p plan
P plan

Prognosis

Possible outcomes

Anatomy

Underlying condition

Complications

Co-morbidities

Potential further surgery (10-100 days)

Home PN

TLC

hpn service here in torbay
HPN service here in Torbay
  • 15pts
  • ? A new full PN pt soon
  • 6/52 MDT combined clinics
  • Homecare service
fluid balance and initial recovery after elective colonic resection1
Fluid balance and initial recovery after elective colonic resection
  • Median passage of flatus was 1 day earlier (3 vs. 4 days, p=0·001);
  • median passage of stool 2·5 days earlier (4 vs. 6.5 days, p=0·001);
d drugs to consider starting
D Drugs to consider starting
  • PPI (po vs. iv)
  • St Marks
  • Anti-motility
d drugs to consider stopping
D Drugs to consider stopping

Anti-motility + obstruction

Pro-motility

  • Loperamide/codeine
  • Opiates
  • Baclofen
  • Metoclopramide
  • Laxatives
  • Others:
  • NSAIDs
what should we encourage jejunostomy pts to eat1
What should we encourage jejunostomy pts to eat?
  • High energy requirements – can be double habitual

May need overnight NG +/- PEG

  • Ideally low fat to aid absorption but this means a greater food volume (tolerance) and can become EFA deficient
  • Normally recommend energy-dense foods with a high salt content: normally high fat and low residue.
  • Little amounts and often - snacks+++
  • Fluids taken with a meal may increase losses
  • Loperamide 30 min pre food
the management of this pt with 140cm jejunostomy
The management of this pt with 140cm jejunostomy
  • PPI, loperamide and codeine.
  • Hypertonic fluids
  • Little and often plus sip feeds
  • PN as a bridge for about a week
  • Elective re-anastamosis 6 months later
  • Off all treatments bar questran
  • Weight stable, but BO ~5-6*/day
in conclusion
In conclusion
  • Early high output ileostomy – watch and wait then gentle anti-motility. Assess for sepsis, obstruction, untreated luminal disease / infection, drugs
  • Intestinal failure

SNAPED

Integrated care from GI surgeons, physicians, radiologists, stoma team, dietitians, nutrition nurses, pharmacists etc.

  • Be wary of fluid XS
pre op ons in gi surgery pts cochrane 2012
Pre-op ONS in GI surgery pts, Cochrane 2012

Standard ONS

IE – AA and n-3 PUFA

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