A systematic approach in the management of a high output ileostomy resulting in a favorable clinical outcome
High output ileostomy is not uncommon and when diagnosed, it should be managed expeditiously and systematically in order to prevent complications such as dehydration, electrolyte disturbance and acute kidney injury. A multi modal regimen consisting of correction of fluid and electrolyte deficit; restriction of oral hypotonic fluids with dietary modifications and use of anti-motility drugs was sequentially and concomitantly introduced to achieve a favourable clinical outcome.
Patient education regarding dietary modifications and recognition of dehydration due to high output stoma is paramount. A co-ordinated multi-disciplinary approach involving the patient, family, dietician, community nurses and hospital doctor is vital. High output stoma is encountered with surgically created stomas such as ileostomy, jejunostomy and colostomy. Different studies have defined a high ileostomy output as more than 1500 mL to 2000 mL per day with signs and symptoms of dehydration.
Studies have indicated that almost 16% of patients develop a high output stoma, of which 27% need to be managed conventionally. This results in fluid and electrolyte imbalance culminating in a state of dehydration and acute kidney injury. Current management guidelines for high-output stomas focus on supportive measures and medications that decrease bowel motility. However, response to therapy is often variable and the plan needs to be modified based on the initial fluid status, electrolyte deficit, severity of dyselectrolytemia and response to anti motility agents.
A 75 year old gentleman with a history of hypertension and diabetes mellitus underwent an open anterior resection for carcinoma sigmoid colon with colorectal anastomosis under general anesthesia and invasive hemodynamic monitoring. Post-operatively patient had an uneventful recovery.On the seventh day, he developed colicky abdominal pain with distension and vomiting. A Computerised Tomography of Abdomen and Pelvis revealed a collection around the anastomotic site and intestinal obstruction.
Patient underwent an emergency laparotomy under general anesthesia and invasive hemodynamic monitoring, which revealed a contained anastomotic leak and defunctioning ileostomy was performed. Postoperatively, total parenteral Nutrition (TPN) was initiated to provide nutrition. Oral feeds were initiated once the ileostomy started functioning. TPN was tapered and stopped prior to discharge to the ward.
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