Meagan Bridges, RD Clinical Dietitian and Nutrition Support Specialist, University of Virginia Health System Charlottesville, VA. Roseann Nasser, MSc RD CNSC FDC Research Dietitian – Nutrition and Food Services Pasqua Hospital – Regina, Saskatchewan Health Authority. Carol Rees Parrish, MS, RDN Nutrition Support Specialist University of Virginia Health System Digestive Health Center Charlottesville, VA.
Recent years have seen a dramatic increase in readmission rates among patients with ileostomies who present with dehydration and/or kidney injury. High readmission rates are often the result of a failure to anticipate what will happen after discharge. Preventing readmission and preserving kidney function in these patients starts with reliable and accurate data collection – including not just stool output, but urine as well – and continues with detailed follow-ups to optimize medications, fluid, and food intake. Supporting patients through the entire process also requires educating them and equipping them with tools to gather and track their output. As clinicians, it is incumbent upon us to develop and execute a practical plan for adequate hydration and output management to not only prevent kidney injury, but also improve the quality of life for these patients.
A 46-year-old male with history of ulcerative colitis (diagnosed at age 26), status post total proctocolectomy with J-pouch (1998), proximal diversion with loop ileostomy with 270cm small bowel remaining (2005), presented in 2018 following 5 days of emesis and high output from his ileostomy, ultimately found to be secondary to a narrowing in his ileum causing outflow diarrhea.
His medications at the time of consult included a PPI BID, 5 mg Lomotil QID, 8 mg Imodium QID, Metamucil TID, cholestyramine BID, oxycodone PRN, and 50 mcg sandostatin q8h.
He is 6’ 2” and has maintained a weight of 250-255 lb for years. His BUN and creatinine were 28 and 1.3 respectively, with a reported 24 hour urine output of 1 liter during the winter months, but stated he sometimes goes a day or so without urinating in the summer. He also reports over 300 kidney stones – the first one occurring within 3 months of his loop ileostomy – with over 20 lithotripsies, all of which were managed at an outside facility hence, the surgeon who performed the loop ileostomy was unaware of any of this. After years of failing to meet his hydration needs and repeated bouts of nephrolithiasis, he finally lost his left kidney. During this admission, it was determined that he needed 3 L of IV fluids nightly to prevent dehydration and to protect his remaining kidney.
Cases like the one above are not uncommon among patients with ileostomies. As Table 1 shows, recent years have seen a growing focus on readmission rates for dehydration and/or acute kidney injury (AKI) among this population (possibly as a result of stipulations in the Affordable Care Act aimed to decrease hospital readmissions in general).1 New ileostomy patients are often sent home well hydrated from IV fluids while admitted and with minimal output owing to decreased post-op appetite and intake, but this often does not reflect what will happen after discharge when patients are left to hydrate themselves and their appetite and oral intake picks up. In one study, it was shown that patients readmitted for AKI presented with a 3-fold increase in ileostomy output between post-op discharge and readmission (an average of 13 days later).2 Another study found that patients had significantly decreased GFR at ileostomy closure compared to pre-op ileostomy creation for any cause.3 Finally, Li et al. showed that 25% of patients with ileostomies develop CKD within 2 years, likely due to recurrent, sub-clinical dehydration.4
As clinicians, we are tasked with intervening not only to prevent kidney injury, but also to ease the other clinical and psychological burdens as well as quality of life challenges that so many patients with high-output ileostomies face (Table 2).
High Output Defined
As Table 3 shows, there can be many causes of high output, which in turn may lead to dehydration and kidney injury. A normal, mature ileostomy should only make about 1200mL of output each day (Table 4). Jejunostomies can initially put out up to 6 L, but this too will decrease with the help of medication. On the other hand, colostomies usually only put out 200-600mL/day. In the literature, “high output” is loosely defined as > 1500mL/day.
Acute Kidney Injury and Dehydration
As of 2011, expanded guidelines have been proposed based on serum creatinine levels and urine volume, widening the scope of what it means to have an AKI (Table 5). Dehydration, however, is a bit more nebulous. While there is no single way to define it, one of the best indicators is whether a patient is able to make enough urine (>1200mL/ day). Other indicators are listed in Table 6. Note that dark urine can sometimes be a side effect of a particular medication, rather than a sign of dehydration. Make sure to ask patients if they have ever been admitted for dehydration (whether at your own or another outside facility) and/or been to the emergency department and received IV fluids or experienced a kidney stone.
Treating and Preventing Dehydration: What to Do When an Ileostomy Patient is Readmitted
Treatment for dehydration will look different in ileostomy patients vs. those without ileostomies. In addition to fluid resuscitation with IV fluids, high output ileostomy patients are often told to drink more by mouth. Drinking more, however, does not mean absorbing more fluid and in fact, in some, will drive ileostomy losses further, resulting in even worse dehydration or volume depletion. In patients suffering from ongoing malnutrition, sweetened liquid nutrition supplements (such as Ensure/Boost, etc.) are often recommended, but these too are known to drive stool losses in those with high output. Some patients may notice that if they drink less fluid, their bothersome ileostomy output decreases, but then so does their urine output, often to a volume well below a liter per day. Unfortunately, while many patients are taught to record their stool or ileostomy volume, most are not educated to measure urine also, and this is the most important guide to hydration in these patients. Stool or ileostomy output may look great, but it may come at the expense of an adequate urine output, which may ultimately result in renal demise and chronic kidney insult.
Importance of Ins and Outs (I&O)
For dehydrated, high output ileostomy patients, the first step is to ascertain the patient’s true GI anatomy (if not known). If the operative report is unclear, consider ordering an abdominal CT to determine a patient’s anatomy and/or the presence of any strictures. If this is not an option, a small bowel follow-through can help determine gross anatomy and transit time through the GI tract.
For an accurate 24-hr I&O while an ileostomy patient is admitted, an order for “Strict or Measured I&O” vs. just “I&O” will ensure greater accuracy–i.e., not just if/when the patient stooled or emptied their ileostomy bag, but the actual volume of each occurrence. In many cases, it is worth having a discussion with the nursing staff to clarify the difference between I&O and Strict I&O. It is also very important that both floor and wound and ostomy nurses document if a patient’s ostomy is leaking, or bursting, so all know that the ostomy volume recorded in the medical record is less than what the losses really are. In general, goal urine output should be around 1200mL (or in the case of kidney stone formers, at least 1500mL) each day. Ideally, a goal stool output should be < 1500mL/ day, not just to reduce the risk for dehydration, AKI or kidney stones, but also to improve the patient’s overall quality of life. Providing patients with the tools to measure both urine and ostomy output is essential (see Figures 1-4).
Patients with high ostomy output are at risk for sodium depletion as jejunal and ileal effluent contain 80-140mEq sodium per liter respectively. It will be important to provide enough sodium in the patients IV fluids to reflect this and adjust as the output is brought down under control. One way to determine if your patient is sodium replete is to obtain a 24 hour or random urine Na level; < 10mmol/L suggests Na depletion.5,6
Osmotic vs Secretory Diarrhea
Some patients who present with high output will require differentiating between osmotic and secretory diarrhea. These patients will need to be NPO for 24 hours with IV fluids and possibly parenteral nutrition (PN), if also malnourished. If ileostomy output significantly drops during this time, then it is osmotic in nature and can at least be partially managed by reducing food and/or fluid intake (and replacing with IV fluids as needed). The added benefit of this approach is that your patients will be able to see for themselves how eating and drinking directly drive output. If, on the other hand, ileostomy output remains over 500-800mL/24 hours, then it is considered a secretory diarrhea and will require a different medication and treatment approach.
Determining a Malabsorptive Component If you suspect malabsorption, collect a 48-72 hour fecal fat to determine the degree. A patient with severe malabsorption may require PN, whereas a patient with mild to moderate malabsorption may see enough improvement with diet/beverage changes, along with antidiarrheal and antisecretory medications. For younger patients, a 48-hour sample is usually sufficient, but Medicare beneficiaries will need to complete a 72-hour collection. Whichever test you use, ensure that your patients are ingesting/infusing 100 g fat per day either orally or enterally. A patient cannot malabsorb fat if they do not ingest it.
Food and Fluid Considerations
There is limited data on specialized diets for ileostomy patients other than those with known short bowel syndrome. Our clinical experience, however, suggests that these patients may benefit from a “relative” short bowel diet, at least until their output is well under control. In general, this diet is high in complex carbohydrates and low in sugar alcohols (contained in many liquid medications7), sugar, and sugary beverages (Table 7).8-11 Those with an end jejunostomy or ileostomy will need additional salt. Once a patient’s output is under control, it is important to begin liberalizing the diet as tolerated to avoid unnecessary restrictions and potential nutrient deficiencies.
Overall fluid intake is patient-specific. In general, hypertonic fluids, which pull water into the small bowel and thereby increase stool volume, should be avoided altogether.12 This includes fruit juice/drinks, regular sodas, sweet tea, syrup, ice cream, sherbet, sweetened gelatin, and liquid nutrition supplements such as Ensure, Boost or store brand equivalents. Small amounts of hypotonic fluids, such as water, tea, coffee, alcohol, and diet sodas, are allowed. However, bear in mind that hypotonic fluids will pull sodium into the small bowel; sodium in turn will pull water with it, thereby increasing stool volume as well. Initially, a drastic fluid restriction (e.g. <120mL with meals plus sips of water with meds for 24 hours) can be a powerful demonstrator to the patient regarding just how much oral fluids can drive output. Remember that all patients will still need to maintain a urine output of at least 1200mL/day; hence, some patients will need the addition of IV fluids while undergoing this trial.
Oral rehydration solutions (ORS) will not reduce stool output, but can be helpful in enhancing absorption of fluid in select patients. Consider trialing ORS with a small amount at first (e.g. 500mL sipped throughout the day). Some patients may prefer ORS in the form of ice cubes or popsicles. Other patients may benefit from a nocturnal infusion via gastric feeding tube as an alternative to IV fluids. A nasogastric trial is recommended first before placing more permanent access to ensure success (and not keeping the patient up all night with yet even more output). In addition to several ready-made commercial products available, patients can make their own ORS at home. See “A Patient’s Guide to Managing Short Bowel Syndrome” (available at no cost) for recipes.
Fiber Bulking Agents
Fiber bulking agents may thicken ostomy effluent from a jejunostomy or ileostomy, but they may hinder absorption of nutrients from food in the small bowel. In stable, well-nourished patients who have a colon, fiber bulking agents can be tried if desired by patient to improve the viscosity of stool, which in turn may improve quality of life (although there is a paucity of data to support benefit in this population). However, in the setting of malnutrition or poor appetite and PO intake, avoid filling your patients up on fiber supplements at the expense of other vital nutrients. In addition, fiber bulking agents may exacerbate electrolyte depletion by binding up minerals preventing absorption. Finally, while fiber bulking agents may thicken stool, they do not hydrate the patient as the water is now bound up in the fiber that is excreted in stool.
A number of medications can be used to slow down GI transit and reduce ileostomy output. Tables 8 and 9 list specific antidiarrheal and antisecretory agents that are commonly used to slow output. When maximum doses of loperamide (Imodium) (2-3, QID) and diphenoxylate/ atropine (Lomotil) (2, QID) are taken and ostomy output remains >1500mL/day, it is time to consider stronger gut slowing medications like opioids. In addition to the analgesic effects of opioids they:
- Delay gastric emptying
- Disturb the migrating motor complex
- Slow intestinal transit
- Increase anal sphincter pressure
- Inhibit water and electrolyte secretion
- Increase fluid absorption
thereby, allowing more time for fluid absorption to take place with a reduction in stool output.13 Likewise, Histamine-2 receptor blockers will not be as effective in reducing gastric secretions as proton pump inhibitors (PPI). In those patients deemed to be net-secretors, if oral PPI is not effective (possibly due to inadequate surface area for absorption), IV PPI, maximum dose, BID should be tried. Finally, octreotide/sandostatin can be very effective in those who have failed all other interventions. A dose of up to 500mcg q 8 hours may be needed in some.
Bile Acid Binders
Bile acid binders (cholestyramine, etc.) are often ordered in an effort to reduce high output. However, they are not appropriate for patients who have an end jejunostomy or ileostomy. The whole purpose of a bile acid binder is to protect the colon from the caustic effects of bile acids that pass through the ileum (normally, 95% of bile acids are reabsorbed in the last 100cm of ileum through the very efficient process of enterohepatic circulation). Unabsorbed bile salts that escape to the colon reduce transit time, decrease fluid resorption, and increase fluid secretion into the colon. As a result of fat malabsorption and calcium binding, they can also potentially lead to increased absorption of unbound oxalate.14 If one does not have a colon, the only thing bile acid binders will do is aggravate fat malabsorption and bind important minerals, nothing more. Bile acid binders are best reserved for patients with terminal ileal resections of <100cm or those with a diseased ileum, and, a colon segment in continuity. In addition to worsening fat malabsorption, fat-soluble vitamin status will need to be monitored more closely; screening for signs and symptoms of essential fatty acid deficiency annually may be wise as well.
The Total Pill Count
It is essential to review a patient’s medication list thoroughly and reduce the oral pill burden wherever possible. This includes prescription and over-the-counter medications, as well as vitamin/mineral supplements. Remember that the more pills a patient has to swallow, the more fluid he/she will be drinking, which can further increase output. For example, Lomotil and Imodium often require large, frequent doses (16-20 tablets/day) and can still leave a patient with a daily stool output of over 1500mL. Codeine, on the other hand, is much more efficient at slowing the gut with fewer pills (often around 4 tablets/day). Tincture of opium is also effective, but is much more expensive, often not covered by insurance, and is not readily available at pharmacies. It also requires good eyesight to measure the dropper dose, and has a particularly unpleasant taste.
The Curse of “PRN” Orders
In hospitalized patients, “PRN” medications are often not given. Yet, in a patient with high output, to be effective, it is not only imperative to schedule these medications, but to ensure they are taken before meals/snacks to avoid the “wash out effect.” Some will achieve better efficacy if crushed. Medications such as sustained, controlled, and delayed-released, as well as elixirs/suspensions with sugar alcohols should be avoided. Additional pharmacological considerations are listed in Table 10.
Finally, it is worth mentioning glucagon-like peptide 2 (GLP-2), an intestinotrophic, endogenous peptide released from the distal ileum and proximal colon that enhances gut adaptation in response to enteral nutrients. It inhibits gastric acid secretion and may slow emptying; stimulates intestinal blood flow; increases intestinal barrier function; and enhances nutrient and fluid absorption. In recent years, the GLP-2 analog, Teduglutide (Gattex/Revestive), has demonstrated effectiveness in reducing output and IV fluid / PN requirements in those patients with a high output from short bowel syndrome, provided they meet criteria (Table 11).
When an Ileostomy Patient Goes Home: Tools for Success
Before a patient is discharged home or to a facility, if possible, stop all IV fluids and monitor urine output for 2 days to ensure the patient can make adequate urine volume (1200mL). Also make sure patients have been educated on what is “normal” ileostomy output, what is “high output,” what their goal urine output is before they go home, and who to call if questions or problems arise. In addition, provide patients with the proper tools to successfully measure and track their output and manage all their medications. Stool hats, other ileostomy measuring devices, and urinals (see Figures 1-4), are essential for accurate stool and urine output measurements. A chart for tracking stool/ileostomy output, urine output, and date/time is also essential for monitoring trends and optimizing a patient’s regimen. For example, if a patient always records a large stool mid-afternoon, he/she may need to increase gut-slowing medications beforehand. Provide specific volumes for daily fluid/ORS recommendations; if the clinician is not sure a patient understands the volume intended, provide bedside pitchers with graduated markings or other containers to demonstrate the amount needed. Recommend a pill crusher for those medications that can/would benefit from crushing, and send your patients home with the small 30mL medication cups (see Figure 5) to keep the medication at the ready on their bedside table when gut-slowing medications need to be taken in the middle of the night (thus minimizing competition with food, fluid, and other medications).
Once a patient has left the hospital, closer and earlier follow-up (1-2 weeks post-discharge), along with routine labs and ongoing nutrition counseling will also help prevent readmissions. See summary suggestions in Table 12. For articles and handouts that can help clinicians and patients alike, visit the UVAHS GI Nutrition website and click on “Nutrition Articles” and “Patient Education.”
Hydration is essential to preventing kidney injury in patients with ileostomies who already have enough challenges to face as is. Most readmissions for dehydration and acute kidney injury can be avoided with proper planning and anticipatory guidance, along with early and thorough follow-up. Paying closer attention to electrolytes, both stool and urine measurements, along with medication and diet management, can dramatically improve our ileostomy patients’ quality of life and reduce readmissions and complications. Also see Table 13 for the new University of Virginia Health System diet/hydration handout developed to help prevent readmission for AKI after new ileostomy creation.