High output stoma

1. High output stoma Richard Johnston 06/09/13

2. Case of: • High output ileostomy • Jejunostomy

3. Elective Small Bowel resection Baseline Recently 39 yrs old lady 6yr history of recurrent stricturing CD Right hemi 5yr ago no cigs BO 3*/day 5-ASA B12 nil else Obstructive episodes 2 * 5-10cm distal SB strictures Weight loss of 7kg from 66kg BMI 23 No oedema

4. Laparotomy Findings Procedure extensive distal small bowel disease with a walled off perforation around the neo-terminal ileum Adhesions++ abscess and distal small bowel was fully removed en masse with no drains inserted Primary anastomosis was not made colon remained in situ end ileostomy formed. remaining small bowel was assessed to be healthy and ~ 3.5 m in length.

5. Day 5 post-op Clinical assessment Stoma volume 3 litres/day sepsis/obstruction No clinical evidence 24 hours urinary volume 800 ml iv fluids nil Oedema nil Eating little Drinking 2.5 litres of squash/water/tea renal biochemistry normal

6. Day 5 post-opWhat to do? Clinical assessment Stoma volume 3 litres/day sepsis/obstruction No clinical evidence 24 hours urinary volume 800 ml iv fluids nil Oedema nil Eating little Drinking 2.5 litres of squash/water/tea renal biochemistry normal

7. Early high output Ileostomy • >2l/day • Present in 20% of ileostomies • Normally no cause found, and resolves in >50% • Mortality ~ 8% (sepsis) • Aetiology: Obstructed Sepsis – intra-abdominal Enteric disease: Inflammation/infection - C Diff Medication Short bowel: Jejunostomy Nightingale et al. Colorectal Disease 2009

8. Losses depend where it comes from NICE 2013 Page 40 of 189

9. Losses depend where it comes from NICE 2013 Page 40 of 189

10. Small bowel stoma + electrolytes • Under-replaced salt and water losses Rising urea and creatinine Low sodium – serum or urine Secondary hyperaldosteronism: low magnesium and potassium Low Potassium = dehydrated (assuming > 50cm jejunum) • NOT phosphate – if low then pt refeeding

11. Plasma, ileal fluid and iv fluid contents

12. Plasma, ileal fluid and iv fluid contents

13. Dangers of sodium and fluid XS • Our ancestors faced dehydration • Nature has developed many strategies to overcome sodium and water deficiency • No methods to excrete XS sodium or water • So no defence mechanism to abnormal saline

14. Fluid and electrolyte balance Clinical Lab Fluid balance charts Weights Oedema 30ml/hr Urinary sodium <20mmol/L: secretor/ retainer Plasma urea and creatinine (catabolic state, low protein intake and reduced muscle mass) Sodium low Magnesium and potassium low

15. Oral hypertonic fluids • Can avoid iv fluids in ¾ patients and nutrition support in 2/3 • 500-1000ml hypotonic fluids/day Nightingale et al. 2009

16. Hypertonic fluids

17. Supportive medical management for a high output stoma • Start PPI – gastric hypersecretion, no change in macronutrient absorption Loperamide (?syrup) – enterohepatic circulation Codeine Octreotide – reduces high output stoma losses but no benefit on energy/nitrogen balance and may induce fat malabsorption. Expensive and painful NB: Loperamide and codeine CI in obstruction • Stop NSAIDs, laxatives, prokinetics • Screen C diff

18. Case continued... Urinary Na 7 mmol/L 2L Hartmann’s Daily fluids: 500 ml oral hypotonic fluids 1 litre hypertonic glucose–saline increase oral food intake loperamide 8mg qds omeprazole 40 mg bd Stomal losses 1-1.5L/day Mobile

19. What can she eat with her new ilesostomy? • What she likes vs. • Low residue

20. Day 9 Fevers, vomiting and RIF tenderness CT – collection and obstruction Laparotomy – adhesions and internal fistulae Surgical drain and stoma re-fashioned at 140cm HDU Iv antibiotics

21. What are the Issues? Solutions ?

22. What are the Issues Solutions Sepsis PEM 140cm SB

23. What are the Issues Solutions Sepsis PEM 140cm SB Antibiotics and drain EN / PN .....

24. Intestinal failure ‘inabilityto maintainprotein-energy, fluid, electrolyte or micronutrient balance from either obstruction, dysmotility, surgical resection, congenital defect or disease associated loss of absorption’. Sub classified into three types: • Type 1 Self-limiting. E.g. ileus, IF is temporary and often predictable support fluid, electrolytes +/- nutrition with PN • Type 2 Intestinal failure in severely ill patients Major bowel resection or a septic patient with metabolic or nutritional complications. Most overcome their initial acute illness with only a few develop type 3 IF • Type 3 Chronic intestinal failure requiring long term nutritional support Chronic intestinal failure even after resolution of the acute illness and intestinal adaptation.

25. Long-term requirements by jejunal length

26. Assessment Sepsis Nutritional status – energy, protein, electrolytes Anatomy Plan Edema (fluid balance) Drugs • S • N • A • P • E • D

27. Open abdomen with jejunal fistulation

28. S sepsis • may not be classical, can get C diff in SB • Low threshold for CT • Culture lines

29. S sepsis in this pt • We have a cunning plan of antibiotics and drain

30. N nutritional statusclinical assessment Macronutrient Micronutrient MUST Recent intakes Weight loss signs Anthropometry Current dry weight urea and creatinine Albumin Low K, Phos, Mg predict refeeding risk No role for a ‘full nutrient profile’

31. The case... • Day 10 post admission with little orally during admission and pre-ceding PEM • Handgrip - weak • No oedema but further 2kg wt loss • Low urea and creat • Normal K, Mg and PO4 • Albumin .......

32. Albumin in healthy volunteers after 2l fluid in 1hr Clin Sci 2003. Lobo et al.

33. Very low albumin often looks like...

34. A anatomy Jejuno-colon Jejunostomy • Adaptation via peptide YY • No adaptation

35. Long-term requirements by jejunal length

36. P plan Prognosis Possible outcomes Anatomy Underlying condition Complications Co-morbidities Potential further surgery (10-100 days) Home PN TLC

37. HPN service here in Torbay • 15pts • ? A new full PN pt soon • 6/52 MDT combined clinics • Homecare service

38. Edema

39. Fluid balance and initial recovery after elective colonic resection Lobo et al Lancet 2002

40. Fluid balance and initial recovery after elective colonic resection • Median passage of flatus was 1 day earlier (3 vs. 4 days, p=0·001); • median passage of stool 2·5 days earlier (4 vs. 6.5 days, p=0·001);

41. D Drugs to consider starting • PPI (po vs. iv) • St Marks • Anti-motility

42. D Drugs to consider stopping Anti-motility + obstruction Pro-motility • Loperamide/codeine • Opiates • Baclofen • Metoclopramide • Laxatives • Others: • NSAIDs

43. What should we encourage jejunostomy pts to eat?

44. What should we encourage jejunostomy pts to eat? • High energy requirements – can be double habitual May need overnight NG +/- PEG • Ideally low fat to aid absorption but this means a greater food volume (tolerance) and can become EFA deficient • Normally recommend energy-dense foods with a high salt content: normally high fat and low residue. • Little amounts and often - snacks+++ • Fluids taken with a meal may increase losses • Loperamide 30 min pre food

45. The management of this pt with 140cm jejunostomy • PPI, loperamide and codeine. • Hypertonic fluids • Little and often plus sip feeds • PN as a bridge for about a week • Elective re-anastamosis 6 months later • Off all treatments bar questran • Weight stable, but BO ~5-6*/day

46. In conclusion • Early high output ileostomy – watch and wait then gentle anti-motility. Assess for sepsis, obstruction, untreated luminal disease / infection, drugs • Intestinal failure SNAPED Integrated care from GI surgeons, physicians, radiologists, stoma team, dietitians, nutrition nurses, pharmacists etc. • Be wary of fluid XS

48. Nutrition state assessment?

49. MUST

50. MUST