High-Output Ostomy/High-Output Stoma (HOS)

High-Output Ostomy/High-Output Stoma (HOS)

David Ray Velez, MD

Table of Contents

Definition
Risk Factors
Complications
Management

See Also:
*See Ostomy

Definition

High-Ostomy Output Definition: > 1,500 cc/Day Output

Normal Output: 600-1,200 cc/Day

Risk Factors

Risk After Ostomy Creation: 16-31%

  • Most Common After Ileostomy and Rare After Colostomy Creation (1-3% Risk)

Risk Factors

  • Short Bowel
  • Sepsis
  • Diabetes
  • Medications/Prokinetics
  • Inflammatory Bowel Disease
  • Clostridioides difficile Enteritis
  • Opiate Withdrawal
  • Internal Fistula
  • Small Bowel Diverticula
  • Intermittent/Partial Obstruction (Stricture) with Bacterial overgrowth

Complications

Dehydration/Acute Kidney Injury (AKI)

  • Dehydration is the Most Common and Most Clinically Significant Complication of High-Output Stomas
  • Due to Large Fluid Loss within the High Stoma Output
  • Pre-Renal AKI Caused by High Fluid Loss
  • Fluid Replacement:
    • Oral Rehydration is Preferred
    • Limit Hypotonic Drinks (Water, Tea, Coffee, Juice, Soda) – Can Worsen Stoma Losses by Drawing Sodium Out of the Body and into the Bowel
    • Use High Sodium Oral Rehydration Solutions (ORS) Such as Double-Strength Pedialyte with Sodium 90-120 mEq/L
    • Replace Losses ≥ 1:1
    • Add IV Fluid Resuscitation if Oral Replacement is Insufficient (Severe Dehydration, Poor Oral Intake, AKI, etc.)

Electrolyte Abnormalities

  • Hyponatremia
    • High Sodium Loss in Stoma Effluent
    • Patinets Often Drink Large Volumes of Hypotonic Fluid (Water, Tea, Juice) Which Further Worsens Sodium Depletion
    • Dehydration Stimulates ADH Release Causing Water Retention and Further Diluting Serum Sodium
  • Hypokalemia
    • High Potassium Loss in Stoma Effluent
    • Dehydration Stimulates a Secondary Hyperaldosteronism in Which the Kidneys Retain Sodium but Excrete Potassium Further
  • Hypomagnesemia
    • Due to Poor Absorption, Direct GI Losses, and Renal Wasting by Secondary Hyperaldosteronism
  • Non-Anion Gap Metabolic Acidosis (NAGMA)
    • Primarily from High Bicarbonate Losses

Wound Issues

  • Due to Constant Exposure to Large Volumes of Fluid Rich in Digestive Enzymes, Electrolytes, and Bile Salts
  • Causes Skin Irritation and Peristomal Dermatitis
  • Can Lead to Ulceration and Infection
  • Risk for Long-Term Scarring and Fistula
  • Requires Proper Fitting Appliance with Vigilant Monitoring and Protective Skin Barriers

Malabsorption

  • Due to High Transit Times Causing Decreased Absorption
  • Can Cause Malnutrition
  • Can Cause Impaired Medication Absorption – Particularly in Extended-Release Formulations

Management

Initial Immediate Management Consists of Fluid Resuscitation and Electrolyte Replacement Due to Excessive Losses

First-Line: Soluble Fiber Supplement (Psyllium/Metamucil)

  • Absorbs Water to Slow Transit Time
  • Often Dosed as “Packets” in the Hospital EMR
    • Each Packet Generally Contains ~ ½ Tbsp (~ 4 g Fiber)
  • Starting Dose: 1 Packet 2-3x/Day
  • Max Dose: 2 Packets 4x/Day
  • *Avoid Insoluble Fiber Supplements (Wheat Bran) – Can Speed Up Transit Time

Second-Line: Common Antimotility Drugs

  • Loperamide (Imodium)
    • MOA: A Peripherally Acting Mu-Opioid Receptor Agonist to Reduce GI Motility
    • Generally the Preferred First Antimotility Medication (Lower Side Effects Than Diphenoxylate-Atropine)
    • Starting Dose: 2 mg 4x/Day
    • Max Dose: 8 mg 4x/Day
    • Caution: High Doses > 16 mg/Day Can Prolong QTc with Risk for Cardiac Arrhythmias
  • Diphenoxylate-Atropine (Lomotil)
    • MOA: A Centrally Acting Opioid Derivative to Reduce GI Motility
      • Atropine Added to Discourage Misuse
    • Starting Dose: 2.5 mg (One Tablet) 4x/Day
    • Max Dose: 5 mg (Two Tablets) 4x/Day

Tertiary Options:

  • Tincture of Opium
    • MOA: Binds Mu-Opioid Receptors in the GI Tract to Slow Motility
    • Uncommonly Available in Patient
    • Dose: 6 mg (0.6 mL) 4x/Day (Max: 6.0 mL/Day)
  • Codeine
    • MOA: Binds Mu-Opioid Receptors in the GI Tract to Slow Motility
    • Dose: 15 mg 2x-4x/Day
  • Octreotide
    • MOA: Synthetic Somatostatin Analog Decreases GI Secretions and Slows Motility
    • Dose: 100 mcg 3x/Day or 12.5-50 mcg/hr Continuous Infusion
  • Cholestyramine
    • MOA: A Resin that Sequesters Bile Acids to Decrease Bile Acid Secretion and Diarrhea
    • Generally Only Used for a High-Output Colostomy with Terminal Ileum Resection in Which there is Concern for a Bile Acid Etiology
    • Avoided in End Ileostomies Due to Worsened Fat Absorption and No Improvement in Output
  • PPI/H2-Blockers
    • Anti-Secretory Effects
    • Pantoprazole Dose: IV 80 mg 2x/Day or PO 40 mg 2x/Day
    • Famotidine Dose: 20-40 mg 2x/Day (PO or IV)

“Start Low and Go Slow” When Increasing Pharmacologic Regimens

Persistent Difficulty May Be Considered for Early Ostomy Reversal if Appropriate