Professional Documents
Culture Documents
1. Introduction.
1.1 These guidelines set out the identification and management of patients with a high output
stoma including reducing and replacing fluid and electrolyte losses, drug management,
nutritional support, and ongoing monitoring of an adult patient with a high output stoma.
1.2 A high output stoma is defined as one which produces more than 2000ml/day (for more than
3 days), or one in which the volume has not been measured accurately or is producing less
than 2000ml daily but there is ongoing issues with fluid and electrolyte balance.
2. Scope
2.1 This guideline applies to adult patients with an ongoing high stoma output, irrespective of the
patient’s clinical area or setting (inpatients, daycase, outpatients).
2.2 The aim of this document is to reduce complications of high output stoma by promoting
evidence based practice amongst medical, nursing and health care professionals working with
this patient population.
2.3 While the guideline is aimed at patients on surgical/medical wards, certain aspects (such as
the use of medication to reduce intestinal losses) are transferable to other areas, such as
critical care, oncology.
2.4 The following professional groups are authorised to use this guideline:
Surgical / medical teams
Pharmacists
Senior Specialist Dietitians
Nutrition Nurse Specialists
Colorectal and Stoma Care Nurse Specialists.
Appendix Title
1 Management of Fluid and Electrolytes
2 Medication to Reduce High Output Stoma Volume
3 Nutritional Support for Adult Patients with a High Output Stoma
4 Monitoring patients with a High output stoma and ongoing referral
5 St Marks Instructions for Oral Hydration / Electrolyte Replacement
(Standard Electrolyte Mix)
6 St Marks Instructions for Oral Hydration / Electrolyte Replacement
(Sodium Citrate)
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NB: Paper copies of this document may not be most recent version. The definitive version is held on INsite Documents
Summary Guidance on the Management of a High Output Stoma
Restrict ORAL FLUIDS to 500ml daily (Meet fluid /electrolyte needs intravenously)
Commence loperamide 4mg QDS to reduce stoma losses. This should be given
30-60minutes before meals and at bedtime (if using capsules open and mix with
jam/yogurt. Once gut transit time has been reduced whole capsules can be
swallowed and the effect on stoma output monitored).
Monitor strict fluid balance, daily weights, and serum biochemistry, including bone
profile and magnesium levels.
Review stoma output after 48-72hours – if settles increase oral fluid intake.
STAGE 2: Ongoing HOS – optimise treatment with anti-secretory /
diarrhoeal medication
EXCLUDE Clostridium difficile INFECTION – Send stoma output for culture
Continue oral fluid restriction. (If stoma output is >3000ml/day consider placing the
patient NBM for 24 hours to assess gastrointestinal secretions).
Commence St Marks glucose-electrolyte replacement solution 1000 ml daily, orally,
in addition to oral fluid restriction (this replaces stoma sodium losses but will still
increase output if taken in excessive amounts). Once IV fluids are stopped, check
random urine sodium (aim >20mmol/l).
Review proton-pump inhibitors. Initiate or change to Esomeprazole/Omeprazole
40 mg OD-BD to reduce volume of gastric secretions and stoma volume.
Increase loperamide dose to 8mg QDS
Add in codeine phosphate 15mg – 60mg QDS, 30-60minutes before meals (use
cautiously in patients with renal impairment and contraindicated if GFR<15).
STAGE 3: REFER TO NUTRITION TEAM for additional treatment if
HOS continues
loperamide dose can be increased by 2-4mg (re-assess every 2-3days. Only
increase further if a significant improvement in output is seen. Maximum dose is
24mg QDS).
If stoma output remains >2000ml daily after 2weeks of therapy initiate octreotide
200microgrammes TDS for 3-5 days. If no significant improvement stop. If
improvement consider longerterm analogues.
Review compliance to oral fluid restriction and St. Marks solution.
Continue strict monitoring (fluid balance charts, weights, weekly magnesium levels).
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4. Education and Training
The professional staff authorised to use this guideline as detailed in section 2 must have received
relevant training in this patient population and accept responsibility for updating knowledge and
skills on a regular basis to maintain competence. The nutrition team can provide training to relevant
clinical areas / specialities on request
Reporting
Element to be Monitored Lead Method Frequency
arrangements
Patients using this Melanie Baker, Audit Tool – Every 2 CSI CMG board
guideline have been Senior retrospective years
appropriately identified Specialist case note
(i.e. have a recorded Dietitian review
high output stoma of
more than 2000ml daily,
or has ongoing issues
with fluid/electrolyte
management).
7. Key References
Baker M L, Williams R N & Nightingale JMD (2011) Causes and management of a high-output stoma,
Colorectal Diseases, 13(2);191-7
Baker ML, Nightingale JMD (2003a) Management of Entercutaneous fistulae. A Nutrition Support Team’s
Experience, Clinical Nutrition, 22Suppl1;56
Baker M L, Nightingale JMD (2003b) More salt please! Management of a high output stoma. Clinical Nutrition,
22Suppl1:52
Carlson G, Gardiner K, McKee R, Macfie J, Vaizey C (2010) The surgical management of patients with acute
intestinal failure, Association of the Surgeons of Great Britain and Ireland, London
Condon, R., Nyhus, L. (1993) Manual of Surgical Therapeutics. 8th ed., Little & Brown, Boston.
Fatemi S, Ryzen E, Flores J, Endres DB, Rude RK (1991) Effect of experimental human magbesium
depletion on parathyroid hormone secretion and 1,25 dihydroxy-vitamin D metabolism. Journal Clinical
Endocrinol Metabolism, 73:1067-1072
Fordtran JS, Rector FC, Ewton MF, Soter N, Kinney J. (1965) Permeability characteristics of the human small
intestine. J Clin Invest; 1935-1944
Hughes S, Myers A, Carlson G (2001) Care of Intestinal stoma and Enterocutaneous Fistula, cited in
Nightingale J M D, Intestinal Failure, Greenwich Medical
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V3 Approved by Policy and Guideline Committee on 30 May 2014, Trust Ref: B12/2005 Next Review: May 2017
NB: Paper copies of this document may not be most recent version. The definitive version is held on INsite Documents
Jeppesen PB, Staun M, Tjelesen L, Mortensen PB (1998) Effect of intravenous ranitidine and omeprazole on
intestinal absorption o water, sodium, macronutrients in patients with intestinal resection. Gut: 43: 763-769
Kennedy HJ, Al-Dukaili EAS, Edwards CRW, Truelove SC (1983). Water and ilostomy balance in subjects
with a permenant ileostomy. Gut;24:702-705
Hanna S, MacIntyre I (1960) The influence of aldosterone on magnesium metabolism, Lancet, 2:348-350
Lobo DN, Bjarnason K, Field J, Rowlands BJ, Allison SP (1999). Changes in weight, fluid balance and serum
albumin in patients referred for nutritional support, Clin Nutr;18(4): 197-201
McIntyre PB, Fitchew M, Lennard-Jones JE (1986). Patients with a jejunostomy do not need a special diet.
Gastroenterology; 91:25-33
Newton CR, Gonvers JJ, McIntyre PB, Preston DM, Lennard-Jones JE. (1985). Effect of different drinks on
fluid and electrolyte losses from a jejunostomy. J Roy Soc Med; 78: 27-34
Spiller R C, Jones B J M, Silk D B A (1987) Jejunal water and electrolyte absorption from two proprietary
enteral feeds in man: importance of sodium content, Gut, 28, 681-687
8. Key Words
High output stoma, HOS, ileostomy, Jejunostomy,
Approved by: Policy and Guideline Committee Date Originally Approved: 10 January 2005
Latest Approval Date: May 2014 Next Review Date: May 2017
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V3 Approved by Policy and Guideline Committee on 30 May 2014, Trust Ref: B12/2005 Next Review: May 2017
NB: Paper copies of this document may not be most recent version. The definitive version is held on INsite Documents
Management of Fluid and Electrolytes
Appendix 1
1.1 The initial management of a high output stoma should concentrate on reducing fluid and
electrolyte losses. Restricting oral intake is the main stay of treatment, with intravenous
replacement of fluid and electrolyte losses as required.
If stoma output is >3000ml/day place the patient Gastrointestinal secretions (4000ml/24hrs) will be
NBM for 24hours to assess gastrointestinal reduced with no oral intake. This may be beneficial
secretion. as a short term measure, if initial stoma output is
>3000ml daily. This will help improve hydration
status and also assess if the high output is due to
excessive secretion of gastrointestinal fluids.
Review the need for intravenous fluids to Ileostomy output can contain 140mmol of sodium
maintain hydration and replace stoma losses. per litre (Lee et al, 1974).
Fluids with adequate sodium should be given in
depleted patients.
If high stoma losses continue on antidiarrhoeal There is a coupled absorption of glucose and
medication, commence St. Marks glucose- sodium in the jejunum (Olsen, 1968). Sodium
electrolyte replacement solution 1000 ml daily, concentrations >90mmol/l result in sodium
orally (See appendix 5 & 6) absorption and improve sodium balance (Newton et
al, 1985, Nightingale et al 1992).
If compliance to St Marks is a problem – liaise
with the Nutrition Team as other options may be St Marks solution does not reduce stoma volume
suitable per se when compared to the same quantity of
water consumed (Nightingale et al, 1992) It
NB - St Marks solution should not be given in improves sodium balance, which in turn improves
unrestricted amounts as excess consumption will thirst, so that overall fluid intake can be reduced
still increase stoma volume. (when used in conjunction with a hypotonic fluid
restriction). This will then reduce stoma output.
Ongoing need for Intravenous replacement of To prevent electrolyte abnormalities and renal
fluid, sodium (and other electrolytes) must be impairment.
considered. Some patients may require
ongoing/home IV fluids or home parenteral
nutrition (ref to Nutrition Support Team. Appendix
4
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1.2 Hydration Solutions
a) Compliance to oral electrolyte solutions can be a problem. If St Marks is not tolerated
and alternative solution can be made with sodium citrate (see appendices). Other re-
hydration solutions that may be suitable are:
b) Dioralyte – this can used if made up to double strength (to increase the sodium
concentration from 60 – 120mmol/l). This should not be the solution of choice due to
cost and the potassium content (Serum potassium levels must be monitored).
c) Isotonic re-hydration fluids such as Lucozade should not be used to replace St. Marks
Solution as the sodium concentration is too low.
d) Sodium Chloride Capsules -These can be effective in some patients who can not
tolerate oral hydration solutions. Large amounts are required (approximately 10-14/24
hours taken throughout the day with fluid) and can cause nausea and vomiting
(Nightingale et al, 1992).
Commence ongoing oral magnesium This is best given at night when stoma function is
replacement. less and absorption may be improved.
If ongoing hypomagnesaemia ensure water and High stomal losses of sodium and fluid can
sodium depletion is corrected. exacerbate Mg losses. Stoma losses of salt and
water cause hyperaldosteronism, increasing renal
excretion of magnesium (Hanna and MacIntyre,
1960).
If magnesium levels are chronically low, consider A low serum magnesium level reduces both the
prescribing 1-alpha-hydroxcholecalciferol (250 secretion and function of parathyroid hormone
nanograms daily increasing to 500 nanograms). (Fatemi et al, 1991), so magnesium absorption in
the loop of Henle is not promoted, and renal 1-
Serum calcium levels should be monitored and alpha-hydroxylase is not activated to make 1,25-
dose reduced if hypercalciumaemia occurs. hydroxycholecaliferol. Failure to make 1,25
hydroxycholecaliferol reduced magnesium and
calcium absorption from the gut.
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Medication to Reduce High Output Stoma
Volume Appendix 2
Add in codeine phosphate 15mg – 60mg Codeine phosphate in combination with loperamide
QDS, 30-60minutes prior to meals. reduces stoma volume. It should be used cautiously in
patients with renal impairment and is contraindicated in
patients with GFR <15.
Stage 3: Increase medication and Rationale
evaluate efficacy of other options
Increase loperamide dose by 2-4mg (effect Loperamide doses above recommended and licensed
of this should be assess for 2-3 days doses are often needed in patients with intestinal failure.
before increasing the dose further as BSG guidelines recommend a maximum dose of 24 mg
significant additional benefit may be QDS (Nightingale and Woodford, 2006).but this should
unlikely above 8mg QDS). Maximum dose only to used in cases where the effect of low doses has
24mg QDS. been properly considered.
Significant further benefit is often unlikely above 32mg
daily (Carlson et al, 2010)
If stoma output remains >2000ml daily after Subcutaneous octreotide 50micrograms twice daily
2 weeks of therapy try sub/cut octreotide reduces ileostomy/jejunostomy outputs (Nightingale et al,
50-200microgrammes TDS. Give for 3-5 1989) by reducing salivary, gastric and pancreatico-biliary
days. If no improvement stop. secretions and slowing bowel transit. Longer acting
analogues may also be useful. It may not be more
effective than high dose loperamide and a proton pump
inhibitor so these options should be considered first.
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Nutritional Support for Adult Patients with
a High Output Stoma Appendix 3
1) This patient population is at risk of malnutrition due to their underlying disease process
(cancer, inflammatory bowel disease) and treatment (often referred after surgery where
nutritional intake has been compromised).
3) If patients are unable to maintain their nutritional status due to an inadequate nutritional
intake, naso-gastric feeding should be considered. Enteral feeding formulations are low in
sodium and normally need to be given in volumes of 1 -2 litres/day. This will compound
stoma sodium losses. Solutions with low sodium concentrations lead to net secretion of
sodium (Spiller et al, 1987).
4) The sodium concentration of enteral feed may need to be increased if it is not possible to
replace electrolytes by another means. The addition of sodium to enteral feeds, may
increase the risk of feed contamination / infection. It is important to follow UHL guidelines
on administration of additional sodium to enteral feeds.
5) For those patients where enteral nutritional support is deemed inappropriate (malabsorption
will limit effectiveness of treatment and exacerbate stoma losses), Parenteral Nutrition
should be considered. Patients should be referred to the Nutrition Support Team for
assessment.
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Monitoring patients with a High output
stoma and ongoing referral Appendix 4
4.2 To assist with compliance by patient and health care professional involved in the care of a patient with a
high output stoma a ward based management guide is available (see page 3 Summary Guidance on
the Management of a High Output Stoma. These should be used to reduce the risk of different
teams/individuals giving different advice especially around the use of St Marks and hypotonic fluid
restrictions. Patient information leaflets are also available (Managing with a High Output Stoma).
4.3 Local audit has identified that approximate half of patients presenting with a high output stoma settle
within 2 weeks (Baker et al, 2010). Patients with small bowel lengths of <150cm are likely to have
ongoing problems with a high output stoma. The need for antimotility drugs, hypotonic fluid restriction
and electrolyte replacement should be titrated depending on stoma output/consistency and serum/urine
measurements.
4,4 On discharge from hospital patients should have an appropriate plan for follow-up in place. This should
involve regular biochemical monitoring (via GP) and clinical review. Nutrition support teams can offer
ongoing monitoring via outpatient clinics in required.
Ongoing Referral to Nutrition Support Team
If output remains above 2000ml/day start If stoma output settles review ongoing need
Stage 2 management plan for HOS treatment and aim to wean.
REFER TO NUTRITION SUPPORT TEAM If stoma output settles review ongoing need
for HOS treatment and aim to wean.
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St Marks Instructions for Oral Hydration /
Electrolyte Replacement
(Standard Electrolyte Mix) Appendix 5
You have been prescribed St Marks Electrolyte mix. You will need to make up a fresh
solution each day .
Directions:
• 5ml spoon is equivalent to a standard tea spoon
• Mix to dissolve all powder ingredients in one litre of water.
• Use within 24 hours and discard any remaining solution after this time.
• This solution may be diluted with a little fruit squash and refrigerated to make it
more palatable (make sure the total volume of water and squash is one litre).
• Glucose powder and sodium bicarbonate powder (also known as bicarbonate of
soda) is inexpensive and can be bought from any chemist or is available on
prescription from GP.
• Standard table salt available from any supermarket is suitable for use.
• In an emergency situation double strength Dioralyte may be used as a substitute.
If you need to get these prescribed please show your GP/Doctor this leaflet. They will
need to be prescribed in the following way.
If the prescription is written in this way, your community pharmacist can claim for these
items and will be able to supply them to you. If you have queries, contact:
………………………………………………………………………………………………………
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V3 Approved by Policy and Guideline Committee on xxxxx, Trust Ref: B12/2005 Next Review: 2016
NB: Paper copies of this document may not be most recent version. The definitive version is held on INsite Documents
St Marks Instructions for Oral Hydration /
Electrolyte Replacement
(Sodium Citrate) Appendix 6
You have been prescribed Electrolyte mix. You have been unable to tolerate the original
St. Marks mix so you have been prescribed a citrate version. You will need to make up
the solution fresh each day.
Directions
• 5ml spoon is equivalent to a standard tea spoon
• Mix to dissolve all powder ingredients in one litre of water.
• Use within 24 hours and discard any remaining solution after this time.
• This solution may be diluted with a little fruit squash and refrigerated to make it more
palatable (make sure the total volume of water and squash is one litre).
• Glucose powder and sodium citrate powder are inexpensive and can be bought from
any chemist or is available on prescription from GP.
• Standard table salt available from any supermarket is suitable for use
• In an emergency situation double strength Dioralyte may be used as a substitute
If you need to get these prescribed please show your GP/Doctor this leaflet. They will need to
be prescribed in the following way.
If the prescription is written in this way, your community pharmacist can claim for these items
and will be able to supply them to you. If you have queries, contact:
………………………………………………………………………………………………………………
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V3 Approved by Policy and Guideline Committee on xxxxx, Trust Ref: B12/2005 Next Review: 2016
NB: Paper copies of this document may not be most recent version. The definitive version is held on INsite Documents