High Output Syndrome–Ileostomy, Jejunostomy, Enteric cutaneous fistula (ECF)

High Output Stomas/Syndrome (HOS) cause concerns for many reasons to the small bowel ostomate, a person with an enteric cutaneous fistula (ECF) and possibly to the ascending/transverse colostomate.

THE KEY IS TO MONITOR FOR HOS AND TREAT/CORRECT EARLY TO AVOID COMPLICATIONS

The Definitions of HOS vary and HOS is a topic coming more into focus. Conservative definitions lean toward 1000 ml of output in 24 hours for 2-3 days. The high-end volume noted for HOS definition is 2000 ml a day for 2-3 days. Many are settling toward 1500 ml per day for 2-3 days. Then there are patients who have chronic high output that is day after day and can depleted the body of hydration when they do not make the 1000, 1500 or 2000ml level of output.

While the definition is in flux, the effects of HOS are not.

Concerns/Symptoms/Complications to watch for with HOS:

Signs of dehydration– dry mouth, dry skin, low urine output which should be 1200 ml a day at a minimum.
HOS leads to the dumping of electrolytes through the output.

Low sodium can cause altered mental status like confusion, muscle weakness, lethargy, headache

Low potassium can cause muscle weakness, muscles cramping, fatigue, cardiac arrhythmias

Low magnesium leads to muscle weakness, lethargy, twitching facial muscles, cardiac arrhythmias, seizures

Low calcium can cause muscle cramps and spasms, numbness, memory issues/confusion

Malnutrition, protein calorie- most protein absorbed in jejunum, some in ileum. When the output is high, nutrients are not being digested and absorbed properly.

Acute Kidney Injury (AKI) or failure (AKF)- 30-71% of HOS patients develop AKF due to dehydration, with 50% noted in a separate study. AKF with repeated occurrences can develop into chronic kidney disease (CKD), 25% of ileostomates develop CKD within 2 years. Dialysis may be needed for AKI if hydration does not correct the Creatinine level or if develops CKD stage 5.

Predictive Factors for developing HOS:

• Diabetes

• Proctocolectomy, previous gastric bypass surgery (roux-en-y), Whipple procedures, Jejunostomy, Continent fecal diversion failure (IPAA/J pouch), loop ileostomy

• Ulcerative Colitis , Crohn’s Disease, Enteric cutaneous fistulas, Paralytic ileus, Intermittent or partial obstruction, pouchitis

• Greater than 1000 ml/24 hours at hospital discharge

• Use of medications to control output volume

• Use of prokinetics, metformin, withdrawal from steroids or opiates

• Urgent surgical intervention

• Serious inpatient complications

• Bacterial, viral, parasitic infections

• Chemotherapy and/or radiation to the abdomen

• Diet (osmotic diarrhea/hypersecretion) is a common cause of high output

• Age >50

• Net Secretors—people whose GI system produces too much gastric fluids, not a common cause.

Suggestions on what you can do to decrease HOS (consult your doctor when high output is present and talk over these strategies)

Diet:

Short Bowel Syndrome diet -increase complex carbs, increase fat, decrease sugar alcohols
Avoid hypertonic fluids/foods like many sports drinks, juices, soda, sugary foods-sherbet, candy
Limit hypotonic fluids- tea, coffee, large amounts of water
No Boost or Ensure when output is high, they cause increased output; eat more solid protein
Use oral rehydrating solutions to help replace liquids/electrolytes—speak with your doctor
FODMAP diet or low glycemic index diet
Drinking to much fluid causes increased output, sip throughout day, keep mouth moist
4-6 small meals a day, drink fluids minimally with meals

Medications to discuss with your doctors:

There are several medications your doctor can use to slow down your output if diet changes do not slow down the output. Anti-diarrheals, Proton pump inhibitors, H2 blockers, and more.