Table 3. Treatment algorithms for high-output ileostomy.

Stage 1: Check for causes

Take a history and check medications

Review prior operative and pathological reports

Examine patient, paying special attention to signs of malnutrition (ascites, edema, temporal wasting), nutritional deficiencies (skin rashes), and vital signs (blood pressure, pulse, and weight)

Investigations: complete blood count, serum chemistry electrolytes and elements, C-reactive protein, albumin, prealbumin liver function tests, stool culture and clostridium difficile toxin, blood culture, urine culture, electrolytes, specific gravity, sodium, and abdominopelvic imaging

Stage 2: reduce fluid and electrolyte losses

Rehydrate with intravenous fluid

Restrict hypotonic oral fluid intake to 1,000 mL daily

Introduce hypertonic fluids as necessary

Commence loperamide 2 mg four times per day (QDS) ± codeine phosphate 30–60 mg twice a day (BID) when required (PRN)

The dose of loperamide can be increased until a satisfactory output is maintained (≥1,500 mL); dose range can be between 2 and 64 mg four times per day (QDS)

Start omeprazole 40 mg daily or twice daily to reduce volume of gastric secretions

Treat underlying causes of losses and stop medications that increase stoma output (e.g., metoclopramide)

Screen for malnutrition (including body mass index, % weight loss, and current or expected oral intake) and refer to a dietician as appropriate

Monitor the fluid balance, serum electrolyte (sodium, potassium, urea, creatinine, calcium, magnesium), and weight

Supplement electrolytes if required

Review stoma output in 48–72 h and if this settles oral fluid intake can be increased

Stage 3: ongoing high-output enterostomy

Continue oral fluid restriction. (If stoma output is >3,000 mL/d, consider placing the patient NBM for 24 h to assess gastrointestinal secretion.)

Commence WHO or St Mark's electrolyte solution 1,000 mL daily, orally, in addition to oral fluid restriction

Once IV fluids are stopped, check random urine sodium (aim >20 mmol/L)

Start omeprazole 40 mg once a day (OD) or twice a day (BID) to reduce volume of gastric secretions

Continue daily monitoring of fluid balance charts, serum electrolytes with twice weekly weights, and weekly magnesium levels

Continue to supplement electrolyte if required

Stage 4: high-output enterostomy persist

Review compliance with oral fluids

Increase loperamide dose slowly up to 40 mg daily

Refer to nutrition support team for further advice

Abbreviations: IV, intravenous; WHO, World Health Organization.

Note: Adapted from Baker et al. ⁶