clinical skills

clinical skills

Practical management to reduce and treat

complications of high-output stomas
This clinical skills series is designed for the nursing professional as a basic overview on key clinical skills
necessary for patient care, clearly presenting common clinical procedures and their rationale, together
with the essential background theory. In this sixth article in the series, Melanie Baker and Lynn Greening
consider the causes and management options for patients with a high-output stoma, both relevant to the
acute hospital setting and for those patients discharged back into the community requiring ongoing care.

Melanie Baker is Senior
Specialist Dietitian,
Leicestershire Nutrition
and Dietetic Service, Leicester,
and Lynn Greening is
Colorectal/Stoma Nurse
Specialist, University Hospitals
of Leicester NHS Trust,
Leicester
Key words
■ Ileostomy
■ Intestinal failure
■ Nutritional support
■ Short bowel
This article has been subject to
double-blind peer review
Small bowel stomas are commonly formed as
an elective or emergency procedure after bowel
resection or to defunction the bowel when
protecting a distal anastomosis or bypassing
an obstruction.
A newly-formed small bowel stoma will
normally start to work within 24 hours, producing
up to 2000 ml of watery output initially. In most
cases the volume and consistency of output
improve over time, although this is dependent
on the patient’s anatomy and their underlying
disease (Carlson, 2001).
Problems with a high-output stoma (HOS)
will normally occur when there is less than
200cm of small bowel remaining (known as
a jejunostomy) or if an ileostomy continues to
produce amounts exceeding 2000 ml/day. In
these cases, frequent monitoring is essential to
avoid complications such as dehydration/renal
impairment, electrolyte abnormalities such as
sodium depletion and hypomagnesaemia, and
undernutrition (Nightingale et al, 2006).
This article highlights the potential causes
and consequences of a HOS and suggests
practical management to reduce and treat
complications.
Background
A HOS can be a challenge for all members of the
multidisciplinary team (MDT). The main aspects
of nursing care include detailed monitoring
of the patient’s fluid balance, containment of
output, maintaining skin integrity and patient
support. An understanding of the effect of
altered anatomy/function on fluid/electrolyte
balance and absorption of nutrients is vital.
Patients with a HOS often have an extended
period as inpatients. Ensuring good management
and continuity of care by ward nurses is therefore
paramount. They must be vigilant in recording
accurate fluid balance in order to help the team
make their assessments. If the patient is known
to the colorectal/stoma nurse specialist, they
will also help educate the staff and monitor
fluid balance charts, and demonstrate how to
continue with any prescribed regimes. Patients
often find taking a note of their own fluid
balance makes them feel more in control at
such a frustrating time in their recovery.
Containing such high outputs can be difficult.
Outputs of 7 litres a day, such as the jejunostomy,
produce a higher concentration of digestive
enzymes which not only corrode the skin when
in contact with it, but dissolve the hydrocolloid
on the stoma pouch leading to leakage. The
irritant reaction results in pouch adhesion
difficulties and inevitable pouch leakages (Lyon
and Beck, 2003). It is essential these patients are
referred to the colorectal/stoma nurse specialists
promptly to provide education to ward staff
and patients, thus ensuring the correct stoma
appliance and accessories are used.
Monitoring is essential for the medical
management of a patient with a HOS; however,

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 clinical skills
‘With high it is important to consider how this will affect
the patient psychologically. Stoma formation is
stoma losses,
a life-changing event.
patients become The colorectal /stoma care nurse should
thirsty and the be involved as early as possible as they are
natural response instrumental in providing support not only
during the patient’s time in hospital, but once
is to increase
they are at home (Lyon and Smith, 2003). This
their intake of support continues, with home visits, community
normal fluids, clinics and open telephone contact as the
which are low patient requires. Colorectal/stoma care nurses
in salt’ are often an important first point of contact for
identifying and advising on the management of
complications and providing important liaison
with the rest of the MDT team.
Definition of a HOS
The length of small bowel remaining is often
used as a guide to determine which patients
will require long -term fluid / elec troly te
supplementation and nutrition support.
Parenteral nutrition/saline is normally required
if less than 100 cm of small bowel remains. If
small bowel length is 100–200 cm, oral fluid/
electrolyte management will still probably be
required (Nightingale, 2003). It is important
to take into consideration the quality of the
remaining small bowel – if residual disease
such as cancer or Crohn’s disease remain,
patients with more than 200 cm of small
bowel may still encounter problems. Volume of
daily output will also determine who requires
management to reduce fluid and electrolyte
losses (Table 1).
Locally, a HOS has been defined as patients
w ith les s than 20 0 cm of small b owel,
daily output exceeding 2000 ml, or those
developing biochemical complications such as
hypomagnesaemia.
Little information is available from the
literature about the incidence of postoperative
HOS. The authors’ local data reviewed all
colorectal surgery which resulted in a small
bowel stoma over a 5-year period (2001–2006)
and identified a HOS in 16% of patients. In
approximately half of these patients, high
outputs were transient and settled within
2 weeks of stoma formation. Other causes
included intra-abdominal sepsis/obstruction,
enteric infection (such as Clostridium difficile),
12
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and medication (sudden withdrawal of steroids
or use of prokinetics). It is important to exclude
these causes in postoperative patients. While
the majority of acute HOS resolve, 27% will
require ongoing management in terms of
oral/enteral or intravenous fluid, electrolytes
and nutrition, and most of these patients will
have remaining bowel lengths of less than
200 cm (Baker et al, 2009).
Complications can also develop sometime after
surgery. Examples include exacerbation of Crohn’s
disease, intermittent bowel obstruction due to
adhesions or patients with radiation enteritis
following pelvic radiotherapy (Table 2).
Management
If a patient requires home parenteral nutrition,
this should be managed by an experienced
MDT. Services for home parenteral nutrition
are currently the focus of a national review
by the Department of Health, entitled Home
Parenteral Nutrition and Intestinal Failure clinical
network (HIFNET). This is, however, outside the
scope of this article, which instead focuses on
the management of patients more likely to be
seen outside of specialist centres.
Knowledge of small bowel function, and
the physiological changes that occur when a
patient has a HOS, can help direct appropriate
therapy. The case study shown in Box 1 highlights
the importance of optimizing medication and
nutritional treatment to reduce complications.
Fluid and sodium needs
Ileostomy outputs contain a large amount of
sodium (approximately 100 mmol/litre sodium,
which is equivalent to approximately 6g salt).
If daily stoma volume is normal (600–1200 ml),
sodium and fluid requirements can be met by
encouraging an adequate fluid intake and a
high-salt diet. Problems of sodium depletion
often occur if output exceeds 2000 ml/day
(but can occur with outputs in the region of
1500–2000 ml/day) if sodium losses are not
adequately replaced.
Sodium depletion can be difficult to diagnose.
Symptoms of sodium depletion include excessive
thirst, oliguria, headaches, nausea and a postural
fall in blood pressure of more than 15 mmHg
(Jeejeebhoy, 2001). A useful marker is the
gastrointestinal nursing vol 7 no 6 July/August 2009
 clinical skills

Table 1. Long-term requirement for fluid, sodium and nutrition based on small bowel length and daily stoma output
Small bowel length Daily stoma output Fluid /electrolyte requirements Nutrition requirements
Less than 100 cm Less than 3000 ml Intravenous (IV) saline ± magnesium Parenteral nutrition
101–200 cm 2000 ml to less than 3000 ml Oral glucose-electrolyte solution Parenteral or enteral
(and hypotonic fluid restriction) ± IV nutrition may be needed
Less than 200 cm 1200 ml to less than 2000 ml Try normal fluids. Glucose-electrolyte High-salt diet ± oral
solution may be needed nutritional supplements
if required
Less than 200 cm Less than 1200 ml Normal fluid intake Normal diet ± extra salt
Adapted from: Nightingale and Woodward (2006)

replace with a glucose-electrolyte solution,

Table 2. Causes and consequences of a high-output stoma
Causes
• Small bowel less than 200 cm
• Intra-abdominal sepsis
• Intestinal obstruction (at stoma site or proximal)
• Enteric infection (Clostridium difficile)
• Active disease (Crohn’s disease, cancer)
• Radiation enteritis
• Medication (sudden withdrawal of steroids, prokinetics, laxatives)
Consequences
• Water and sodium depletion (thirst, postural hypotension, urinary
(sodium ion) less than 20mmol/litre; urine output less than 800ml/d, renal
impairment)
• Hypomagnesiumaemia (serum magnesium less than 0.7 mmol/litre)
• Malnutrition (due to malabsorption or food avoidance to alleviate
symptoms)
• Frequent emptying of stoma bag/leakage/skin care problems
measurement of the sodium concentration
in urine. A low level (less than 20 mmol/litre)
indicates sodium depletion and is a sign that
the kidneys are trying to conserve sodium due
to large gastrointestinal losses. A urine sodium
concentration can be low before there is a
change in the serum sodium level.
When patients with high stoma fluid/sodium
losses become thirsty, the natural response is
to increase intake of normal fluids, which are
low in salt. This compounds the problem as
fluids with less than 90 mmol/litre sodium result
in a net loss of sodium from the body into the
stoma (Newton et al, 1985).
In this case the most important treatment is
to restrict low sodium fluids (including sport
hydration drinks which do not contain enough
sodium) to 500–1000 ml daily (Nightingale et
al, 1992). This can be difficult to achieve when
patients have normally been ill-advised to increase
their fluid intake. Sodium/fluid losses must be
1000–2000 ml daily, which contains enough
sodium to result in sodium absorption from the
intestine (Table 3). In severe cases, intravenous
fluids (0.9% saline) will be needed and high
losses can be significantly reduced by placing
the patients ‘nil by mouth’ for 24–48 hours.
Compliance to glucose-electrolyte solutions
can be an issue – it is vital that the importance
and rationale for taking them is explained to
the patient/relatives/carers. Patient information
leaflets are useful. Solutions should be chilled
and mixed well before use. Palatability can
be improved by adding sugar-free squash
– but the volume of this should be taken into
account when making up the solution (so not
to over dilute it).
If patients can not tolerate glucose-electrolyte
solutions orally, a nasogastric or gastrostomy
tube can be used. In some cases, oral hydration
solutions are not successful in maintaining
hydration/sodium balance and intravenous
therapy may be required – either subcutaneously
where a small needle is placed under the
skin and a litre of saline can be given over
approximately 12 hours (although oedema
is a problem and the site must be regularly
rotated). Saline can be given via a cannula as
a day-case procedure or at home 2–3 times
weekly. Peripheral access is often a problem
in these patients, so a Hickman line may be
required for long-term central venous access.
In this case, management/line care should be as
strict as those patients who receive parenteral
nutrition, to avoid infection.
Medication is often required to reduce stoma
losses (Nightingale et al, 2006). High doses of
anti-diarrhoea medication, such as loperamide,

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 clinical skills

Table 3. Oral glucose-electrolyte solutions

Name
St Mark’s Solution or World Health
Organisation cholera solution
without potassium
Dioralyte® (Sanofi-Aventis)
Composition
Sodium chloride 60 mmol (3.5 g);
sodium bicarbonate 30 mmol (2.5 g);
glucose 110 mmol (20 g); water
(1000ml); sodium concentration
90mmol/litre)
Make double strength – 1 sachet
in 100 ml (sodium concentration
120 mmol/litre)
Comments
Can be mixed with squash (use sugar-free to avoid
making the solution hypertonic). Total volume
when made should be 1000 ml. The individual
ingredients can be prescribed.
Dioralyte® contains 20 mmol potassium per sachet.
Therefore, serum levels should be regularly
monitored. Use cautiously in patients with renal
impairment
From: Nightingale (2001)

are often needed because absorption is reduced.

The GP may be reluctant to prescribe more than
4 mg four times daily, unless this is explained
to them. Anecdotally, the authors have seen
HOS patients readmitted with acute renal
failure because high-dose medication has been
stopped after hospital discharge.
Codeine phosphate may be used in addition
to loperamide and it is important that both are
taken 30 minutes before food, and capsules
opened if they emerge in the stoma output.
Antisecretory drugs, such as proton pump
inhibitors (omeprazole), are also used to reduce
stoma losses by reducing gastric secretions.
It is important to remember that normally
approximately 6 litres of gastrointestinal
secretion are produced daily which need to
be reabsorbed (Guyton and Hall, 2006).
Magnesium
Hypomagnesaemia (serum levels less than
0.7mmol/litre) can cause muscle cramps, tetany,
disorientation and cardiac arrhythmias. Low
serum magnesium levels are common; the
authors’ local audit showed that 49% of HOS
patients required magnesium supplementation
(Baker et al, 2009). Causes of low magnesium are
multiple and due to bowel resection (reducing
area of absorption), dehydration (loss of salt
and water causes hyperaldosteronism, which
increases the kidneys’ absorption of sodium
at the expense of potassium/magnesium, and
malabsorption of dietary fat which may bind
with the magnesium salts). If patients have
low magnesium levels but are also sodium
depleted, it is important to correct both. Oral
supplements (magnesium oxide or magnesium
Box 1. Case study example
Background
A 56-year-old woman with Crohn’s disease was referred 5 months after a
subtotal colectomy with ileorectal anastomosis and a defunctioning loop
ileostomy (120 cm small bowel remaining). She had undergone four previous
bowel resections. Her current body mass index is 18.2 kg/m2. She had 21%
weight loss over the previous 5 months
Current problems
Dehydration, hypomagnesaemia requiring regular IV: 0.9% saline with
magnesium sulphate at local hospital
Medication
Loperamide (8mg four times daily), cocodamol (6 tablets per day), fruit-based
nutritional supplement (200ml three times a day)
Biochemistry
Serum urea of 11.2 mmol/litre (normal is less than 6.7mmol/litre), creatinine
of 121umol/litre (normal is 60–120 umol/litre), sodium of 140mmol/litre,
potassium of 3.4mmol/litre, magnesium 0.61mmol/litre (normal is more than
0.75mmol/litre) and C-reactive protein less than 5. Her random urine sodium
level was 42mmol/litre
Stoma output
Approximately 1700ml/day
Dietary food/fluid intake
2500kcal/day, excessive normal fluids secondary to thirst
Management
1. Restrict oral fluids (1000ml/d) and start St Mark’s Glucose-Electrolyte
Solution (1000ml/day)
2. Change nutrition supplement to Peptamen® with added salt (reduced
osmolality compared with fruit-based supplement)
3. Educate patient on appropriate timings of medications (30 minutes before
meals) and ensure the patient is not passing capsules whole into the stoma
4. Start oral magnesium oxide (to increase oral magnesium) and proton pump
inhibitor (to reduce gastric secretions)
Outcome
• Body mass index improved
• Stoma output reduced
• Requirement for intravenous saline/magnesium reduced
glycerophosphate: three 4 mmol capsules)
should be given at night when intestinal transit

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 clinical skills
Table 4. Nutritional composition of common supplement drinks
Type of supplement
Milk-based (non-fibre):
Clinutren® (Nestlé),
Ensure Plus® (Abbott),
Fortisip® (Nutricia),
Fresubin® Energy (Fresenius Kabi)
Fruit-based:
Clinutren® Fruit (Nestlé),
Ensure Plus Juce® (Abbott),
Fortijuce® (Nutricia), Resource®
Fruit Flavour Drink (Nestlé)
Other supplements (which may be of benefit due to low osmolality):
Peptamen® (Nestlé),
Peptamen® Vanilla Cup (Nestlé)
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Energy (9Kcal/100 ml) Protein (g/100 ml)
150 Kcal/100 ml 5.1–6.25 g/100 ml
125–150 Kcal/100 ml 3.75–4.8 g/100 ml
100 Kcal/100 ml 4.0 g/100 ml
Peptide
is slowest. Regular subcutaneous (4 mmol in
1000 ml saline) or intravenous magnesium
(10–20 mmol in 1000 ml saline) may be needed
to maintain normal serum levels.
Nutrition
There is limited evidence regarding the most
appropriate composition of diet/oral nutritional
supplement to use in patients with HOS. Studies
using jejunostomy patients contain very small
subject numbers and are often mixed with
patients who have short bowel with colons
remaining (the two groups of patients behave
very differently when the macronutrient [fat,
carbohydrate, fibre and protein] composition
of the diet is altered) (Woolf et al, 1983;
Jeppesen et al, 1998).
In jejunostomy patients the mean percentage
of energy absorbed is constant irrespective of
the composition of the diet (Nordgaard et al,
1994). As patients’ requirements are high due
to malabsorption, an energy-dense diet (high
in fat and moderately low in fibre) should be
encouraged, based on regular meals with
additional snacks. While increasing the dietary
fat intake will increase losses of fat in the stoma,
this is not felt to be particularly harmful. A strict
low-fibre diet is not normally required – patients
will report that some foods are not well digested,
such as sweetcorn or mushrooms. Other patients
may find some food results in bloating/wind.
Rather than advising food avoidance, foods that
were previously enjoyed should be tried; with
Osmolality (mOsmol/kg) Sodium (mmol/litre)
400–790 mOsmol/kg 34–52 mmol/litre
360–955 mOsmol/kg 4.0–67 mmol/litre
240 mOsmol/kg 26 mmol/litre
340 mOsmol/kg 26 mmol/litre
some foods the pleasure of eating them as an
occasional treat may outweigh any problematic
effect on bowel function.
If a patient has symptoms of intermittent
bowel obstruction (such as bloating, distension,
gripping abdominal pain and excessive stoma
output normally after a period of reduced
stoma function), then a strict low-fibre diet can
reduce symptoms/stoma function and prevent
the ongoing need for fluid and electrolyte
replacement.
Nutritional supplements/tube feeds
If patients are unable to tolerate or absorb
adequate amounts orally from diet, then nutritional
supplements (sip feeds) or enteral nutrition
(nasogastric feeding) may be needed.
There is a vast array of different nutritional
supplements available. Very few studies have
considered the optimal type of supplement to
use in patients with a HOS. Two studies have
considered type of protein source: polymeric
(whole protein as found in a normal diet) vs
peptide (the protein has been supplied in a
simpler form). In one study (Cosnes et al, 1992),
nitrogen absorption was significantly improved
using a peptide formulation. Although this was
not shown in the other study (McIntyre et al,
1986), the fat content and osmolality of the
two products tested also varied.
The aim of enteral nutrition is to improve
nutritional status without further exacerbating
losses of fluid and electrolytes from the stoma.
gastrointestinal nursing vol 7 no 6 July/August 2009

This can be difficult as enteral formulations are
low in sodium (approximately 40 mmol/litre)
and often have a high osmolality, which may
be detrimental in term of sodium balance.
In healthy volunteers, the initial sodium
concentration of the solution correlates
significantly with sodium absorption in the
jejunum (Spiller et al, 1987). Considering
that low-sodium fluids are normally restricted
in HOS patients, it would seem sensible to
increase the sodium concentration of sip
and tube feeds. Additional sodium chloride
can be added to tube feeds as 30% sodium
chloride (10 ml provides 51 mmol/litre), but this
is against manufacturers’ recommendations.
Locally, the authors have increased the salt
content of sip feeds by adding salt sachets
(1g sodium chloride equals 17 mmol sodium).
Interestingly, sodium-depleted patients do not
seem to notice a change in taste. Otherwise
supplement drinks should be counted as part
of the low-sodium fluid restriction.
Osmolality of the products used should
be considered, aiming for approximately
300 mOsmol/kg. Therefore, standard whole
protein (polymeric) products are normally
recommended as smaller molecules, such as
peptides, amino acids, increase the osmolality
of the product. Peptamen® (Nestlé), a peptide-
based feed, has an unusually low osmolality
(Peptamen ® Vanilla Cup is 340 mOsmol/kg)
and may have some benefit for these patients,
although research studies are needed to confirm
this. Table 4 provides some guidance on standard
nutritional supplements. It is important to review
the composition of individual supplements as
there is significant variation between them.
Further research is required to ascertain the
most appropriate formulation to use with this
patient group.
Conclusion
Management of a patient with a high-output
stoma requires a multidisciplinary approach,
utilizing the expertise of clinicians, nursing,
pharmacy and dietetics. The psychological
effect of a high-output stoma should not be
underestimated. With education and ongoing
support of patients to optimize medication and
nutritional treatments, complications can be
reduced or avoided. ■
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clinical skills
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