NUTRITION ISSUES IN GASTROENTEROLOGY, SERIES #190                                                                                                                                        NUTRITION ISSUES IN GASTROENTEROLOGY, SERIES #190
         Carol Rees Parrish, MS, RDN, Series Editor
         High Output Ileostomies: 
         The Stakes are Higher than the Output
                  Meagan Bridges                         Roseann Nasser                         Carol Rees Parrish
                     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.
         CASE STUDY
               46-year-old male with history of ulcerative              His medications at the time of consult included a 
               colitis (diagnosed at age 26), status post               PPI BID, 5 mg Lomotil QID, 8 mg Imodium QID, 
         Atotal proctocolectomy with J-pouch (1998),                    Metamucil TID, cholestyramine BID, oxycodone 
         proximal diversion with loop ileostomy with 270cm              PRN, and 50 mcg sandostatin q8h. 
         small bowel remaining (2005), presented in 2018                    He is 6’ 2” and has maintained a weight of 
         following 5 days of emesis and high output from                250-255 lb for years. His BUN and creatinine 
         his ileostomy, ultimately found to be secondary to             were 28 and 1.3 respectively, with a reported 
         a narrowing in his ileum causing outflow diarrhea.             24 hour urine output of 1 liter during the winter 
                                                                        months, but stated he sometimes goes a day or so 
         Meagan Bridges, RD Clinical Dietitian and Nutrition            without urinating in the summer. He also reports 
         Support Specialist, University of Virginia Health System       over 300 kidney stones – the first one occurring 
         Charlottesville, VA Roseann Nasser, MSc RD CNSC                within 3 months of his loop ileostomy - with over 
         FDC Research Dietitian - Nutrition and Food Services           20 lithotripsies, all of which were managed at an 
         Pasqua Hospital - Regina, Saskatchewan Health                  outside facility hence, the surgeon who performed 
         Authority Carol Rees Parrish, MS, RDN Nutrition                the loop ileostomy was unaware of any of this. 
         Support Specialist University of Virginia Health               After years of failing to meet his hydration needs 
         System Digestive Health Center Charlottesville, VA             and repeated bouts of nephrolithiasis, he finally 
         20                                                                 PRACTICAL GASTROENTEROLOGY • SEPTEMBER 2019
                                                      High Output Ileostomies: The Stakes are Higher than the Output
NUTRITION ISSUES IN GASTROENTEROLOGY, SERIES #190              NUTRITION ISSUES IN GASTROENTEROLOGY, SERIES #190
          Table 1.  Readmission and Dehydration and/or                           Table 2.  The Clinical Burden 
                      AKI in Patients with Ileostomies                                      of High-Output Ileostomies
           Year      Citation                     N      Dehydration              •	 Low urine output        •	 Fatigue
                                                          &/or AKI*               •	 Dehydration             •	 Frequent leakages 
            2001 Beck-Kaltenbach15              107           19%                 •	 Electrolyte             •	 Peristomal skin 
            2002  Hallböök16                    222           32%                   Imbalances                  complications
            2012  Gessler17                     250           18%                 •	 Nephrolithiasis         •	 Social isolation
                     Hayden18                   154           20%                 •	 AKI                     •	 Reduced physical activity
                     Messaris19                 603            7%                 •	 CKD                     •	 Depression
                     Nagle20                    161           16%                 •	 Dialysis                •	 Overall well-being
            2013  Paquette21                    201           17%                3-fold increase in ileostomy output between post-
                               3                                                 op discharge and readmission (an average of 13 
            2014  Gessler                       308           19%                              2
                     Glasgow23                   53         39/33%               days later).  Another study found that patients had 
                     Phatak24                   294           11%                significantly decreased GFR at ileostomy closure 
                            25                                                   compared to pre-op ileostomy creation for any 
                     Tyler                     6007            9%                       3
                                                                                 cause.  Finally, Li et al. showed that 25% of patients 
            2015  Villafranca26                  43           30%                with ileostomies develop CKD within 2 years, 
                                                                                                                                               4
            2016  Li4                            84           17%                likely due to recurrent, sub-clinical dehydration.
                             28                                                      As clinicians, we are tasked with intervening 
                     Orcutt                     104           14%                not only to prevent kidney injury, but also to ease 
            2017  Iqbal29                        23           65%                the other clinical and psychological burdens as well 
                     Fish30                     113           41%                as quality of life challenges that so many patients 
            2018  Justiniano31                  262           37%                with high-output ileostomies face (Table 2). 
          * Does not include ER visits/admissions at outside facilities          High Output Defined
                                                                                 As Table 3 shows, there can be many causes of high 
          lost his left kidney. During this admission, it was                    output, which in turn may lead to dehydration and 
          determined that he needed 3 L of IV fluids nightly                     kidney injury. A normal, mature ileostomy should 
          to prevent dehydration and to protect his remaining                    only make about 1200mL of output each day (Table 
          kidney.                                                                4). Jejunostomies can initially put out up to 6 L, but 
          INTRODUCTION                                                           this too will decrease with the help of medication. 
                                                                                 On the other hand, colostomies usually only put 
          Cases like the one above are not uncommon among                        out 200-600mL/day. In the literature, “high output” 
          patients with ileostomies. As Table 1 shows, recent                    is loosely defined as > 1500mL/day. 
          years have seen a growing focus on readmission 
          rates for dehydration and/or acute kidney injury                       Acute Kidney Injury and Dehydration
          (AKI) among this population (possibly as a result                      As of 2011, expanded guidelines have been 
          of stipulations in the Affordable Care Act aimed                       proposed based on serum creatinine levels and 
                                                                         1
          to decrease hospital readmissions in general).                         urine volume, widening the scope of what it 
          New ileostomy patients are often sent home                             means to have an AKI (Table 5). Dehydration, 
          well hydrated from IV fluids while admitted and                        however, is a bit more nebulous. While there is no 
          with minimal output owing to decreased post-op                         single way to define it, one of the best indicators 
          appetite and intake, but this often does not reflect                   is whether a patient is able to make enough urine 
          what will happen after discharge when patients are                     (>1200mL/ day). Other indicators are listed in 
          left to hydrate themselves and their appetite and                      Table 6. Note that dark urine can sometimes be a 
          oral intake picks up. In one study, it was shown                       side effect of a particular medication, rather than 
          that patients readmitted for AKI presented with a                      a sign of dehydration. Make sure to ask patients 
          PRACTICAL GASTROENTEROLOGY • SEPTEMBER 2019                                                                                         21
         High Output Ileostomies: The Stakes are Higher than the Output
         NUTRITION ISSUES IN GASTROENTEROLOGY, SERIES #NUTRITION ISSUES IN GASTROENTEROLOGY, SERIES #190190
        if they have ever been admitted for dehydration           Table 3. Possible Causes of High Ileostomy Output
        (whether at your own or another outside facility)          •	 Short bowel syndrome (SBS)
        and/or been to the emergency department and                •	 Poor quality of remaining bowel 
        received IV fluids or experienced a kidney stone.             (acts like SBS)
        Treating and Preventing Dehydration:                       •	 Intraabdominal sepsis
        What to Do When an Ileostomy Patient                       •	 Enteric infection 
        is Readmitted                                                 (C. diff, salmonella, etc.)
        Treatment for dehydration will look different in           •	 Carcinoid
        ileostomy patients vs. those without ileostomies.          •	 Proximal stomas / small bowel fistulas
        In addition to fluid resuscitation with IV fluids, 
        high output ileostomy patients are often told to           •	 Recurrent / active disease 
        drink more by mouth. Drinking more, however,                  (e.g. Crohn’s flare)
        does not mean absorbing more fluid and in fact, in         •	 Medication initiation or steroid withdrawal
        some, will drive ileostomy losses further, resulting       •	 “Outflow” diarrhea from stricture/
        in even worse dehydration or volume depletion.                obstructive process
        In patients suffering from ongoing malnutrition, 
        sweetened liquid nutrition supplements (such as 
        Ensure/Boost, etc.) are often recommended, but            discussion with the nursing staff to clarify the 
        these too are known to drive stool losses in those        difference between I&O and Strict I&O. It is also 
        with high output. Some patients may notice that if        very important that both floor and wound and 
        they drink less fluid, their bothersome ileostomy         ostomy nurses document if a patient’s ostomy is 
        output decreases, but then so does their urine            leaking, or bursting, so all know that the ostomy 
        output, often to a volume well below a liter per          volume recorded in the medical record is less than 
        day. Unfortunately, while many patients are taught        what the losses really are. In general, goal urine 
        to record their stool or ileostomy volume, most           output should be around 1200mL (or in the case of 
        are not educated to measure urine also, and this          kidney stone formers, at least 1500mL) each day. 
        is the most important guide to hydration in these         Ideally, a goal stool output should be < 1500mL/ day, 
        patients. Stool or ileostomy output may look great,       not just to reduce the risk for dehydration, AKI or 
        but it may come at the expense of an adequate urine       kidney stones, but also to improve the patient’s 
        output, which may ultimately result in renal demise       overall quality of life. Providing patients with the 
        and chronic kidney insult.                                tools to measure both urine and ostomy output is 
                                                                  essential (see Figures 1-4).
        Data Collection
        Importance of Ins and Outs (I&O)                          Sodium
        For dehydrated, high output ileostomy patients,           Patients with high ostomy output are at risk for 
        the first step is to ascertain the patient’s true GI      sodium depletion as jejunal and ileal effluent 
        anatomy (if not known). If the operative report           contain 80-140mEq sodium per liter respectively.  
        is unclear, consider ordering an abdominal CT to          It will be important to provide enough sodium in 
        determine a patient’s anatomy and/or the presence         the patients IV fluids to reflect this and adjust as 
        of any strictures. If this is not an option, a small      the output is brought down under control. One 
        bowel follow-through can help determine gross             way to determine if your patient is sodium replete 
        anatomy and transit time through the GI tract.            is to obtain a 24 hour or random urine Na level; 
                                                                                                        5,6
            For an accurate 24-hr I&O while an ileostomy          < 10mmol/L suggests Na depletion.
        patient is admitted, an order for “Strict or Measured 
        I&O” vs. just “I&O” will ensure greater accuracy–         Osmotic vs Secretory Diarrhea
        i.e., not just if/when the patient stooled or emptied     Some patients who present with high output 
        their ileostomy bag, but the actual volume of each        will require differentiating between osmotic and 
        occurrence. In many cases, it is worth having a                                           (continued on page 24)
        22                                                            PRACTICAL GASTROENTEROLOGY • SEPTEMBER 2019
         High Output Ileostomies: The Stakes are Higher than the Output
         NUTRITION ISSUES IN GASTROENTEROLOGY, SERIES #190
        (continued from page 22)                                 short bowel syndrome. Our clinical experience, 
        secretory diarrhea. These patients will need to          however, suggests that these patients may benefit 
        be NPO for 24 hours with IV fluids and possibly          from a “relative” short bowel diet, at least until their 
        parenteral nutrition (PN), if also malnourished. If      output is well under control. In general, this diet is 
        ileostomy output significantly drops during this         high in complex carbohydrates and low in sugar 
                                                                                                                  7
        time, then it is osmotic in nature and can at least      alcohols (contained in many liquid medications ), 
        be partially managed by reducing food and/or fluid       sugar, and sugary beverages (Table 7).8-11 Those 
        intake (and replacing with IV fluids as needed).         with an end jejunostomy or ileostomy will need 
        The added benefit of this approach is that your          additional salt. Once a patient’s output is under 
        patients will be able to see for themselves how          control, it is important to begin liberalizing the 
        eating and drinking directly drive output. If, on the    diet as tolerated to avoid unnecessary restrictions 
        other hand, ileostomy output remains over 500-           and potential nutrient deficiencies. 
        800mL/24 hours, then it is considered a secretory            Overall fluid  intake  is  patient-specific.  In 
        diarrhea and will require a different medication         general,  hypertonic  fluids,  which  pull  water 
        and treatment approach.                                  into the small bowel and thereby increase stool 
                                                                 volume, should be avoided altogether.12 This 
        Determining a Malabsorptive Component                    includes fruit juice/drinks, regular sodas, sweet 
        If you suspect malabsorption, collect a 48-72 hour       tea, syrup, ice cream, sherbet, sweetened gelatin, 
        fecal fat to determine the degree. A patient with        and liquid nutrition supplements such as Ensure, 
        severe malabsorption may require PN, whereas             Boost or store brand equivalents. Small amounts 
        a patient with mild to moderate malabsorption            of hypotonic fluids, such as water, tea, coffee, 
        may see enough improvement with diet/beverage            alcohol, and diet sodas, are allowed. However, 
        changes, along with antidiarrheal and antisecretory      bear in mind that hypotonic fluids will pull sodium 
        medications. For younger patients, a 48-hour sample      into the small bowel; sodium in turn will pull water 
        is usually sufficient, but Medicare beneficiaries will   Table 4.  Normal Ostomy Output Expected 
        need to complete a 72-hour collection. Whichever 
        test you use, ensure that your patients are ingesting/            → Patients Need to Know This
        infusing 100 g fat per day either orally or enterally.    §	Ileostomy: 1200mL (mature ~ 600-800mL)
        A patient cannot malabsorb fat if they do not ingest 
        it.                                                       §	Jejunostomy: up to 6 liters 
        Food and Fluid Considerations                             §	Colostomy: 200-600mL
        There is limited data on specialized diets for           Nightingale JM (Ed). Intestinal failure. Greenwich Medical 
        ileostomy patients other than those with known           Media Limited. London, England, 2001.
                                                   32
        Table 5. Acute Kidney Injury Defined
          Stage Serum Creatinine                Urinary Output            Examples of Expected Urinary Volume
            1     1.5-1.9 x baseline            <0.5 mL/kg/hr for         60 kg female = 180-360 mL
                  OR                            6-12 hrs                  70 kg male = 210-420 mL
                  > 0.3 mg/dL
            2     2.0-2-2.9 x baseline          <0.5 mL/kg/hr             60 kg female = 360 mL
                                                for > 12 hrs              70 kg male = 420 mL
            3     3.0 x baseline                < 0.3 mL/kg/hr            60 kg female = 432 mL
                  OR                            for > 24 hrs              70 kg male = 505 mL
                  Increase to > 4.0 mg/dL       OR
                  OR                            Anuria for > 12 hrs
                  Initiation of CRRT
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