High output stoma
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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 volume3 litres/day

sepsis/obstructionNo clinical evidence

24 hours urinary volume 800 ml

iv fluidsnil

Oedemanil

Eating little

Drinking2.5 litres of squash/water/tea

renal biochemistrynormal


Day 5 post op what to do

Day 5 post-opWhat to do?

Clinical assessment

Stoma volume3 litres/day

sepsis/obstructionNo clinical evidence

24 hours urinary volume 800 ml

iv fluidsnil

Oedemanil

Eating little

Drinking2.5 litres of squash/water/tea

renal biochemistrynormal


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


Plasma ileal fluid and iv fluid contents

Plasma, ileal fluid and iv fluid contents


Plasma ileal fluid and iv fluid contents1

Plasma, ileal fluid and iv fluid contents


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


Hypertonic fluids

Hypertonic fluids


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.


Long term requirements by jejunal length

Long-term requirements by jejunal length


Assessment

Assessment

Sepsis

Nutritional status – energy, protein, electrolytes

Anatomy

Plan

Edema (fluid balance)

Drugs

  • S

  • N

  • A

  • P

  • E

  • D


Open abdomen with jejunal fistulation

Open abdomen with jejunal fistulation


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 .......


Albumin in healthy volunteers after 2l fluid in 1hr

Albumin in healthy volunteers after 2l fluid in 1hr

Clin Sci 2003. Lobo et al.


Very low albumin often looks like

Very low albumin often looks like...


A anatomy

A anatomy

Jejuno-colon

Jejunostomy

  • Adaptation via peptide YY

  • No adaptation


Long term requirements by jejunal length1

Long-term requirements by jejunal length


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


Edema

Edema


Fluid balance and initial recovery after elective colonic resection

Fluid balance and initial recovery after elective colonic resection

Lobo et al Lancet 2002


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 eat

What should we encourage jejunostomy pts to eat?


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


Nutrition state assessment

Nutrition state assessment?


High output stoma

MUST


High output stoma

MUST


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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