Overview
Definition:
A high-output stoma is an ostomy, typically an ileostomy or jejunostomy, that excretes a large volume of fluid (usually > 1500-2000 mL/24 hours)
This can lead to significant fluid and electrolyte disturbances, malnutrition, and skin breakdown.
Epidemiology:
The incidence of high-output stomas varies depending on the underlying pathology, surgical technique, and patient factors, but can affect up to 10-20% of patients with proximal small bowel diversions
Factors include length of resected bowel, distal bowel continuity, and parenteral support.
Clinical Significance:
High-output stomas pose a significant challenge in postoperative care, leading to dehydration, electrolyte imbalances (hyponatremia, hypokalemia, hypomagnesemia), metabolic acidosis, dehydration, and malnutrition
Prompt recognition and management are crucial to prevent serious morbidity and mortality.
Causes And Risk Factors
Etiologies:
Short bowel syndrome secondary to extensive intestinal resection for Crohn's disease, malignancy, trauma, or ischemia
Proximal stomas (jejunal or high ileal) are more prone to high output
Certain surgical anastomotic techniques or adhesions leading to partial obstruction can also contribute.
Patient Factors:
Pre-existing malnutrition, low body mass index, extensive abdominal surgery history, and inflammatory bowel disease are associated with increased risk.
Surgical Factors:
Placement of stoma proximal to significant residual small bowel, absence of an antiperistaltic segment, and excessive bowel manipulation during surgery.
Clinical Presentation
Symptoms:
Excessive stoma output (>1500-2000 mL/day)
Thirst
Decreased urine output
Fatigue and weakness
Muscle cramps
Dizziness
Nausea and vomiting
Abdominal distension.
Signs:
Dehydration: dry mucous membranes, poor skin turgor, tachycardia, hypotension
Electrolyte abnormalities on labs: hyponatremia, hypokalemia, hypochloremia, hypomagnesemia
Metabolic acidosis
Weight loss
Stomal edema or retraction.
Diagnostic Criteria:
Diagnosis is primarily clinical, based on sustained high stoma output (typically >1.5-2 L/day) coupled with signs and symptoms of dehydration and electrolyte derangements
Confirmation via monitoring stoma output and laboratory investigations.
Diagnostic Approach
History Taking:
Detailed history of fluid intake and output
Nature of output (color, consistency)
Time since surgery
Underlying pathology for stoma creation
Previous abdominal surgeries
Medications
Dietary habits
Any symptoms of obstruction.
Physical Examination:
Assess hydration status meticulously: vital signs (HR, BP), capillary refill time, skin turgor, mucous membranes
Palpate abdomen for distension, tenderness, masses
Examine stoma for position, skin integrity, signs of ischemia or retraction
Assess nutritional status.
Investigations:
Basic metabolic panel (BMP) for electrolytes (Na+, K+, Cl-, HCO3-, Mg++, Ca++)
Renal function tests (BUN, creatinine)
Liver function tests (LFTs)
Arterial or venous blood gas (ABG/VBG) for acid-base status
Stool electrolytes and osmolality to differentiate secretory vs
absorptive losses
Nutritional markers (albumin, prealbumin).
Differential Diagnosis:
Gastroenteritis
Small bowel obstruction
High intestinal fistula
Excessive fluid intake
Diuretic use
Inflammatory bowel disease flare.
Management Strategies
Initial Management:
Immediate fluid and electrolyte resuscitation
Central venous access for rapid infusion of IV fluids and electrolytes
Strict intake and output monitoring
NPO status initially for severe cases to reduce intraluminal volume.
Medical Management:
Aggressive intravenous fluid replacement with isotonic crystalloids (e.g., Lactated Ringer's or normal saline) to correct dehydration and electrolyte deficits
Targeted electrolyte repletion based on lab values
Administration of antidiarrheal agents (e.g., loperamide) to reduce intestinal transit time and output
Somatostatin analogs (e.g., octreotide) can decrease intestinal secretions and motility, often used for refractory cases
Probiotic use may be considered.
Surgical Management:
Indications for surgical intervention include failure of medical management, worsening sepsis, severe malnutrition, stomal complications (e.g., strangulation, significant stenosis), or suspicion of ongoing obstruction
Surgical options include stoma revision, stoma relocation to a more distal ileal segment, bowel resection and reanastomosis, or stoma reversal if feasible
Enteral feeding tube placement (e.g., jejunostomy tube) for optimized nutritional support.
Supportive Care:
Nutritional support is paramount
High-calorie, low-volume, low-solute, high-electrolyte diet once oral intake is tolerated
Parenteral nutrition may be required initially
Stoma nurse consultation for optimal appliance management and skin care
Frequent skin barrier changes to prevent peristomal skin breakdown.
Complications
Early Complications:
Severe dehydration
Electrolyte imbalances (cardiac arrhythmias from hypokalemia/hypomagnesemia)
Renal failure
Sepsis
Stomal ischemia or necrosis
Skin excoriation around stoma.
Late Complications:
Chronic malnutrition and weight loss
Vitamin and mineral deficiencies
Stomal stricture or prolapse
Incisional hernia at stoma site
Development of enteroenteric fistula
Psychological impact of chronic stoma dependency.
Prevention Strategies:
Careful surgical planning and technique to preserve adequate bowel length
Appropriate stoma site selection and creation
Early recognition and prompt management of increased stoma output
Patient education on fluid intake and dietary management
Prophylactic use of antidiarrheals or somatostatin analogs in high-risk patients.
Prognosis
Factors Affecting Prognosis:
Extent of residual small bowel
Underlying etiology of resection
Ability to achieve adequate fluid and electrolyte balance
Nutritional status
Presence of complications
Response to medical or surgical management.
Outcomes:
With aggressive management, many high-output stomas can be controlled, allowing for improved fluid balance and nutritional status
However, some patients may require long-term medical therapy or further surgical intervention
Patients with very short bowel may require permanent parenteral support.
Follow Up:
Close follow-up with a multidisciplinary team including surgeons, gastroenterologists, dietitians, and stoma therapists is essential
Regular monitoring of fluid balance, electrolytes, nutritional markers, and stoma function
Education on home management and when to seek medical attention.
Key Points
Exam Focus:
High-output stoma definition (>1500-2000 mL/day)
Common causes: short bowel syndrome
Key management: fluid/electrolyte resuscitation, antidiarrheals, somatostatin analogs
Surgical indications: refractory cases, stomal complications
Nutrition is critical.
Clinical Pearls:
Always suspect high-output stoma in patients with large volumes of fluid output from ileostomy/jejunostomy
Aggressive IV fluid and electrolyte replacement is paramount
Loperamide is the first-line medical management to reduce transit time
Somatostatin is a potent agent for refractory cases
Remember to assess and manage nutritional status proactively.
Common Mistakes:
Underestimating the fluid and electrolyte losses
Delaying aggressive repletion
Inadequate monitoring of intake and output
Inappropriate use of oral rehydration solutions for severe losses
Failure to consider surgical intervention for persistent, uncontrolled output.