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com
CURRICULUM BASED CLINICAL REVIEWS
A practical approach to the
management of high-output stoma
Christopher G Mountford,1 Derek M Manas,2 Nicholas P Thompson1
1
Department of
Gastroenterology, Newcastle
upon Tyne Hospitals NHS
Foundation Trust, Newcastle
upon Tyne, UK
2
Institute of Transplantation,
Newcastle upon Tyne Hospitals
NHS Foundation Trust,
Newcastle upon Tyne, UK
Correspondence to
Dr Christopher G Mountford,
Department of Gastroenterology,
Freeman Hospital, High Heaton,
Newcastle upon Tyne NE7 7DN,
UK; c.mountford@doctors.org.uk
Received 14 August 2013
Revised 4 October 2013
Accepted 5 October 2013
To cite: Mountford CG,
Manas DM, Thompson NP.
Frontline Gastroenterology
Published Online First: [ please
include Day Month Year]
doi:10.1136/flgastro-2013-
100375
Mountford CG, et al. Frontline Gastroenterology 2013;0:1–7. doi:10.1136/flgastro-2013-100375
ABSTRACT
The development of a high-output stoma (HOS)
is associated with water, electrolyte and
nutritional complications. Prompt, careful
assessment and management is required to avoid
rapid clinical deterioration in this patient
population. A multidisciplinary approach to
management ensures the best possible outcome
and quality of life for patients who experience
HOS. This article outlines the important
considerations in the identification and
pathophysiology of HOS. A systematic approach
to the management of the condition is outlined,
considering fluid and electrolyte requirements,
nutrient deficiencies and manipulation of
gastrointestinal absorption, motility and
secretions using medical and surgical therapies.
INTRODUCTION
It is estimated there are 102 000 people
with a stoma in the UK, and approxi-
mately 21 000 new stomas are formed
every year.1 Around 16% of patients with
a stoma will suffer from early high-
output stoma (HOS) and 7% of these
will require ongoing treatment.2
Common misconceptions exist in the
management of HOS and it is essential
that healthcare professionals involved in
the care of these patients are appropri-
ately trained to assess and manage the
problem. Core competency 2.d. of the
2010 Gastroenterology curriculum stipu-
lates that UK trainees should be able to
define the pathophysiology of HOS,
describe the clinical consequences and
manage the fluid, electrolyte and micro-
nutrient disturbances associated with the
condition. In addition to these core com-
petencies, trainees seeking to achieve
advanced nutrition competencies must
demonstrate a more detailed understand-
ing of the management, outcomes and
longer-term problems of patients with
HOS (box 1).
TRAINING MATTERS
DEFINING A HOS
A stoma is an opening, either naturally or
surgically created, which connects a
portion of the body cavity to the outside
environment. Stomas formed from the
bowel are named in relation to their loca-
tion within the gastrointestinal tract.
A stoma formed from proximal small
bowel (less than 200 cm remaining of
small bowel) is referred to as a jejunost-
omy; one formed from the distal small
bowel, an ileostomy, and if formed from
the colon, a colostomy.
There is no agreed definition of HOS.
It has been variably defined as an effluent
of over 1000–2000 mL/24 h. However,
the effluent from a HOS is likely to be
clinically significant when the output
exceeds 2000 mL/24 h, causing water,
sodium and magnesium depletion, with
malnutrition occurring as a late complica-
tion.3 In practice, a HOS is seen most
commonly in jejunostomy patients, and is
unlikely to occur in those with a colos-
tomy with retained small bowel.2 This is
due to the large capacity for water
resorption in the remaining colon of
patients with a colostomy. However, in
patients with jejunocolic anastamosis
with downstream colostomy, HOS can
occur.
CAUSES OF HOS
Surgery, resulting in less than 200 cm of
remaining proximal short bowel and the
formation of jejunostomy is likely to
result in a HOS. This can be referred to
as anatomical short bowel syndrome
(SBS). Common causes of SBS vary
between paediatric and adult populations
and are outlined in table 1.
However, other factors may cause a
HOS in patients with a stoma, but
without a short bowel (functional SBS).
These include intra-abdominal sepsis,
1
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TRAINING MATTERS
Box 1 Gastroenterology Curriculum 2010
Core competency 2.d. Malabsorption
▸ Defines the pathophysiology of fluid and nutrient
malabsorption, including causes, for example, ana-
tomical and functional short bowel syndrome and
high-output stomas
▸ Describes the clinical consequences of malabsorption,
including malnutrition, fluid and electrolyte disturb-
ance and micronutrient deficiency
▸ Manages fluid, electrolyte and micronutrient distur-
bances associated with short bowel syndrome or
high-output stomas
Advanced nutrition competency 3.c. Short bowel: jeju-
nostomy/high-output stoma
▸ Understands the underlying diseases that result in a
jejunostomy being fashioned
▸ Has a systematic approach to investigating the
causes of high-output stoma
▸ Understands the principles of treatment including
restricting oral hypotonic fluid, drinking a glucose-
saline solution and the use of drugs
▸ Knows when parenteral support is needed
▸ Able to predict patient outcome in terms of fluid and
nutritional needs from knowledge of how much func-
tional bowel remains
▸ Knows the long-term problems of having a
jejunostomy
enteritis (eg, clostridium or salmonella), intermittent
obstruction due to strictures, bacterial overgrowth,
recurrent disease in the remaining bowel (eg, Crohn’s
disease), sudden cessation of drugs (eg, steroids or
opiates) and administration of prokinetics (eg, meto-
clopramide). These potential causes must be consid-
ered and excluded at the outset.
PATHOPHYSIOLOGY OF HOS
Approximately 4 L of endogenous secretions pass the
duodeno-jejunal junction daily (0.5 L saliva, 2 L
gastric juice and 1.5 L pancreaticobiliary secretions).4
Digestion in the upper jejunum (up to approximately
100 cm distal to duodeno-jejunal flexure) adds further
secretions until the mid-jejunum, when absorption
becomes the predominant action, resulting in approxi-
mately 1–2 L entering the colon. The clinical signifi-
cance of this is that in patients with a stoma sited in
Table 1 Common causes of anatomical short bowel syndrome
Adults Children
Crohn’s disease Necrotising enterocolitis
Mesenteric ischaemia Mid-gut volvulus
Neoplastic diseases Multilevel small bowel atresia
Radiation enteritis
2 Mountford CG, et al. Frontline Gastroenterology 2013;0:1–7. doi:10.1136/flgastro-2013-100375
the upper 100 cm of jejunum, effluent volume is
likely to be significantly greater than the volume taken
by mouth.
The sodium content of a meal is approximately 10–
40 mmol/L. Salivary, pancreatico-biliary and intestinal
secretions are sodium rich and increase the concentra-
tion gradient between lumen and plasma in the
jejunum to around 90 mmol/L.5 Jejunal mucosa is
highly permeable resulting in rapid water and sodium
fluxes, so the jejunal contents become iso-osmolar.
Sodium absorption can only occur against a small con-
centration gradient and is coupled to the absorption
of glucose, as well as some amino acids, with the
result that there is a net efflux of sodium from plasma
to bowel lumen unless the concentration of solution
within the jejunal lumen is greater than 90 mmol/L.
This physiology is in contrast with the ileum, where
sodium can be absorbed against a concentration gradi-
ent and is not coupled to glucose, hence, why fluid
and electrolyte balance problems are less likely to
occur with an ileostomy.
Intestinal adaptation is a physiological response to
HOS caused by extensive small bowel resection. This
process attempts to restore gut absorption of macro-
nutrients, minerals and water to the ‘pre-insult’ state.
This may be by increasing the absorptive area of
remaining bowel (structural adaptation) and/or by
slowing gastrointestinal transit (functional adapta-
tion). In practice, functional, but not structural,
jejunal adaptation occurs after an ileal resection that
leaves the colon in situ. This is thought to be due, in
part, to high circulating levels of peptide YY and
glucagon-like peptide 2 released from the right colon,
which reduce gastric emptying and small bowel
transit.6 7 These patients may show a gradual reduc-
tion in nutritional requirements over time. However,
there is no evidence for structural or functional adap-
tation in patients with a jejunostomy, and their fluid
and nutritional needs are unlikely to alter with time.3
CLINICAL ASSESSMENT
Assessments of water, sodium, magnesium and nutri-
tional status are essential. A trial of nil by mouth may
be informative to assess baseline stoma output (stoma
output problems may be exacerbated in some patients
who have been wrongly advised to increase their
normal fluid intake or done so because they feel
thirsty). Symptoms may include thirst, lethargy,
feeling faint, muscle weakness and cramps.
Examination should include weight (as well as assess-
ment of weight change), examination of mucous
membranes, postural blood pressure measurements,
anthropometric measures (eg, triceps skinfold thick-
ness, and mid-arm muscle circumference) as well as an
assessment of fluid balance. Referral to a specialist
dietician should be made for their assessment and to
assist the development of a nutrition plan.
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Laboratory measures, including serum urea and cre-
atinine, sodium, potassium, magnesium and urinary
sodium, help quantify the extent of water and electro-
lyte disturbances. The most helpful measure of
sodium depletion is a random urinary sodium which,
if less than 10 mmol/L suggests sodium depletion. It is
helpful to measure these parameters every 1–2 days
initially and ultimately every 2–3 months in those
with long-term problems. Causes for HOS other than
an anatomical SBS should be considered, including
signs of intra-abdominal sepsis. Cross-sectional
abdominal imaging may be appropriate to exclude
this.
An assessment of residual small bowel length (either
from operation notes or from radiological measures)
can help predict outcome in those patients with a jeju-
nostomy or jejunocolic anastamosis with HOS (table 2).
Plasma citrulline can be measured as a marker of small
bowel absorptive capacity.8 However, difficulties
extrapolating this information to calculate parenteral
nutritional requirements in adults mean that its use in
clinical practice is limited.
MANAGEMENT OF SODIUM AND WATER
DEPLETION
Jejunostomy patients have a large stomal output
volume, which increases after eating and drinking.
Each litre of jejunostomy fluid contains approximately
100 mml/L of sodium.9 As referred to earlier, con-
sumption of fluids with a sodium concentration of
less than 90 mmol/L of sodium (hypotonic solutions)
results in a net efflux of sodium from plasma to
lumen until equilibrium is reached. Hypertonic fluids
containing sorbitol or glucose can also cause stomal
losses of water and sodium. Examples of these fluids
are listed below (table 3).
Therefore, patients should be advised to restrict
hypotonic/hypertonic fluids to less than 1000 mL
Table 2 A guide to residual small bowel length and long-term
fluid/nutritional support requirements for patients with high-output
stoma
Likely long-term fluid/nutritional requirements
Jejunal Jejunum-colon with
length (cm) colostomy Jejunostomy
<75 Parenteral nutrition* Parenteral nutrition
+parenteral fluids
75–100 Oral (or enteral) Parenteral fluids±parenteral
nutrition* nutrition
100–150 None Oral or enteral nutrition+oral
glucose/saline solution
150–200 None Oral glucose/saline
*Requirements may reduce with time due to the effects of functional
intestinal adaptation.
This table is adapted from reference 3.
Mountford CG, et al. Frontline Gastroenterology 2013;0:1–7. doi:10.1136/flgastro-2013-100375
TRAINING MATTERS
Table 3 Examples of hypo/hypertonic fluids that should be
restricted
Hypotonic fluids Hypertonic fluids
▸ Water ▸ Coca cola
▸ Tea ▸ Most commercial sip feeds
▸ Coffee
▸ Fruit juice
▸ Alcohol
▸ Dilute salt solutions
daily. In practice, this step is often difficult for patients
because they feel thirsty and their instinct is to drink
more. The remainder of their fluid requirements
should be met by consumption of a glucose-saline
solution (1 L or more with a sodium concentration of
at least 90 mmol/L) sipped in small quantities
throughout the day (box 2). Dioralyte mixed to the
manufacturer’s recommended concentration (5 sachets
with 1 L of water) achieves a sodium content of only
60 mmol/L. Mixing Dioralyte to ‘double strength’
achieves a sodium concentration above the level
required. However, increasing concentrations do
result in reduced palatability and in circumstances
where this is a problem, mixing eight sachets of diora-
lyte with 1 L of water is an acceptable compromise. It
is essential that healthcare professionals are educated
in this area of management to avoid mixed messages
on appropriate fluid intake.
In the initial phase of treatment, if there is marked
dehydration, it is often necessary to rehydrate the
patient first with intravenous normal saline, keeping
the patient ‘nil by mouth’, subsequently withdrawing
intravenous fluids as restricted oral fluids are reintro-
duced. Intravenous saline may also be required as a
long-term therapy in those patients unable to maintain
hydration with the above measures. A random urinary
Box 2 Examples of oral glucose-saline solutions
Modified World Health Organization cholera solution
(also known as St Mark’s solution)
▸ Sodium chloride 60 mmol (3.5 g)
▸ Sodium bicarbonate 30 mmol (2.5 g)
▸ Glucose 110 mmol (20 g)
▸ Water 1 L
Double strength’ Dioralyte (10 sachets)
▸ Sodium 120 mmol
▸ Potassium 40 mmol
▸ Chloride 120 mmol
▸ Citrate 20 mmol
▸ Glucose 180 mmol
▸ Water 1 L
3
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TRAINING MATTERS

sodium of >20 mmol/L should be the target of
treatment.
DRUG THERAPIES
If fluid restriction and consumption of glucose-saline
solution are not adequate to maintain fluid balance,
drugs that reduce intestinal motility or secretions may
be needed (box 3). As intestinal output rises after
meals, especially in net ‘secretors’ (those patients who
lose more water and sodium from their stoma than
they take by mouth) it is important to take the drugs
before meals. Although octreotide has been shown to
reduce large-volume jejunostomy output, injection
may be painful and its long term-use has been asso-
ciated with increased risk of gallstone problems.10
MANAGEMENT OF NUTRIENT DEFICIENCIES
Magnesium deficiency is common in patients with
HOS, due to a combination of reduced absorption
(because of chelation with unabsorbed fatty acids) and
increased renal excretion (due to secondary hyperal-
dosteronism).10 Oral magnesium supplementation,
given as magnesium oxide may be necessary.
Alternative oral agents include magnesium aspartate
and magnesium glycerophosphate, though both are
unlicenced for this indication. Where oral replacement
is insufficient to correct magnesium levels, intravenous
magnesium sulfate, usually mixed in saline can be
administered.
Patients with HOS require a large, total, oral, energy
intake of a diet, in which osmolality is kept low using
large molecules which are relatively high in fat/carbo-
hydrate content.12 Generally, patients should be
advised to take a low fibre diet, avoiding nuts, whole-
meal products and fruits and vegetables with skins in
particular. Hyperosmolar elemental diets should also
be avoided as they will also exacerbate the problem of
HOS. If enteral feed is given, sodium chloride needs
to be added to make the total sodium concentration of
the feed to approximately 90 mmol/L while maintain-
ing osmolality close to 300 mOsm/kg. Parenteral nutri-
tion is required if a patient absorbs less than one-third
of their oral energy intake, and is usually necessary
when less than 75 cm of small bowel remains sited as a
jejunostomy.13
Box 3 Drug therapies for high-output stoma
Antimotility drugs
▸ Loperamide (dose 4–16 mg four times daily)
▸ Codeine phosphate (dose 30–60 mg four times daily)
The effect may be greater if both are taken together11
Antisecretory drugs
▸ Omeprazole (40 mg once or twice daily)
▸ Octreotide (50 mcg twice daily as subcutaneous
injection)
Most patients with HOS will also require long-term
vitamin B12 replacement. Other micronutrient defi-
ciencies are common, in particular selenium; zinc and
vitamins A, D, E and K deficiencies should be consid-
ered and replaced as necessary.
SURGICAL CONSIDERATIONS
Patients with long-term HOS as a consequence of
SBS, who have difficulty managing their hydration
and or nutritional status, may be suitable to be consid-
ered for surgical treatment options. The main aims of
surgery are to correct mechanical obstruction in order
to decrease bacterial overgrowth, and to maximise
bowel length.
Surgery to restore intestinal continuity should be
considered where there is viable ileum or colon distal
to the stoma so that all potentially functional bowel is
used. The colon has additional absorptive function as
well as a ‘braking’ effect on intestinal motility.7
Conversion of a jejunostomy to restore complete con-
tinuity, or even to a colostomy in such circumstances,
can make a considerable difference in relation to
hydration, sodium balance and, therefore, quality of
life. There are, however, potential complications asso-
ciated with restoration of continuity including diar-
rhoea, which may require dietary modification and
the addition of bile-salt-binding agents.
Isolated dilated stagnant sections of bowel are a site
for bacterial overgrowth. If symptoms of bacterial
overgrowth are present, treatment of dilated segments
with tapering should be considered, especially in the
duodenum and jejunum. This procedure involves exci-
sion of the antimesenteric border of the dilated
portion of bowel. This enables more effective peristal-
sis, thus reducing stasis and bacterial overgrowth.
Bowel lengthening procedures are possible, but rely
on the presence of dilated bowel resulting from intes-
tinal adaptation and should therefore be reserved until
at least 6 months to 1 year following initial bowel resec-
tion. Procedures include the longitudinal intestinal
lengthening and tailoring procedure described by
Bianchi,14 where the bowel is divided longitudinally
between the mesenteric and antimesenteric borders
along its dual blood supply, dividing the bowel into two
limbs, each with a blood supply. These two limbs are
then closed and anastomosed end to end, doubling that
length of bowel. More recently, serial transverse entero-
plasty15 has been performed; a procedure that reduces
bowel diameter, increases bowel length, and establishes
isopropulsive bowel continuity without loss of mucosa
to increase functional small bowel length.
Complications of bowel-lengthening procedures are
high, including anastomotic and staple line leaks, bowel
obstruction from adhesions or ischaemic strictures,
bleeding, abscess formation and death. These limitations
of bowel-lengthening procedures have led some authors
to advocate that they should be reserved for those
patients who, after 6 months of bowel adaptation, are

4 Mountford CG, et al. Frontline Gastroenterology 2013;0:1–7. doi:10.1136/flgastro-2013-100375

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tolerating more than half of their feeds enterally, and
would therefore have a greater chance of successfully
becoming fully enterally fed following a lengthening
procedure. In practice, until now, these procedures have
been reserved for selected paediatric cases.
More recently, intestinal transplant has become a
reality in selected centres worldwide. Frequent severe
dehydration associated with HOS in SBS is one of the
indications for referral for consideration of intestinal
transplantation. However, given that 5 year survival for
small intestinal transplantation in the UK is approxi-
mately 50%,16 whereas long-term parenteral nutrition is
approximately 73%,17 transplantation is generally
reserved for those with severe intractable problems asso-
ciated with long-term parenteral nutrition given for SBS
and intestinal failure, such as intestinal failure-associated
liver disease and recurrent line sepsis or thromboses
resulting in loss of central venous access.
OTHER MANAGEMENT CONSIDERATIONS
Gallstones are common in patients with a jejunostomy
or those with a jejunocolic anastamosis, with a preva-
lence of approximately 45%.18 Those with a jejunoco-
lic anastamosis are also at risk of developing renal
stones as a result of increased absorption of dietary
calcium oxalate.3 They should be advised to follow a
low-oxalate diet, which includes avoiding spinach,
rhubarb, parsley, cocoa and tea.
Patients with HOS often experience social difficul-
ties in relation to the large volume of effluent.
Practical problems may be associated with emptying
the bag and embarrassment may result from occa-
sional leakage. Skin care around a stoma site can be
problematic in cases of HOS. Stoma care nurse specia-
lists provide a valuable source of support and advice
in dealing with such problems.
Novel therapies, including intestinal growth factors
may offer a useful therapeutic strategy in select patients.
Teduglutide (a recombinant analogue of GLP-2) has
been shown to increase small intestinal weight and
promote villous hyperplasia in preclinical studies, and
may reduce diarrhoea output, increase intestinal fluid
absorption and reduce parenteral requirements.19
SUMMARY
Poor knowledge among clinicians and healthcare pro-
fessionals also often leads to inappropriate and con-
flicting advice to patients to increase their existing
oral fluid intake in response to the problem of HOS.
Careful assessment of fluid balance and nutritional
status and requirements are necessary before institut-
ing specific fluid and nutritional management plans in
this population. A systematic and multidisciplinary
approach is required to manage this problem effect-
ively. Where the facilities for this do not exist locally,
specialist regional nutrition support teams exist to
support local physicians in their management.
Mountford CG, et al. Frontline Gastroenterology 2013;0:1–7. doi:10.1136/flgastro-2013-100375
TRAINING MATTERS
Best of 5 questions
The cases presented below are based on fictitious cases.
1. A 65-year-old female presented to A+E with acute
onset of severe central abdominal pain. Examination
revealed generalised abdominal tenderness and peri-
tonism. Blood tests showed a severe metabolic (lactic)
acidosis. The patient was taken for a laparotomy to
theatre, where the diagnosis of acute mesenteric
ischaemia with small bowel infarction was made.
Extensive small bowel resection was performed. The
colon was preserved. A stoma was formed and the
operating surgeon noted that the length of small
bowel remaining between duodenojejunal flexure and
stoma measured 120 cm. Which of the following ther-
apies is the patient most likely to require in order to
meet her ongoing nutritional/fluid requirements?
A. Oral (or enteral) glucose-saline solution alone
B. Oral (or enteral) nutrition alone
C. Oral (or enteral) nutrition and oral (or enteral)
glucose-saline solution
D. Parenteral nutrition alone
E. Parenteral nutrition and parenteral saline
Answer 1C. This patient has a jejunostomy with 120 cm
of residual small bowel. The remaining colon is defunc-
tioned and not in continuity with the small intestine and
so has no absorptive function. Jejunostomy patients with
this length of small bowel are likely to require oral (or
enteral) nutritional supplementation as well as oral (or
enteral) glucose-saline solution to meet their fluid and
nutritional requirements. Following a prolonged period of
stabilisation and optimisation of nutritional status, surgery
to restore intestinal continuity with the remaining colon
can be considered, particularly if fluid balance remains a
problem despite oral rehydration solutions.
2. A 35-year-old male presents with feeling thirsty, fatigue,
headaches and lightheadedness, particularly on standing.
He has been drinking more water over the past week but
without relief of his symptoms. Past history includes mul-
tiple small bowel resections for fistulating Crohn’s disease,
and at the time of his last surgery 3 weeks ago a jejunost-
omy was formed with 170 cm of remaining small bowel.
Residual bowel was disease free. He reports that the
output from his stoma has been approximately 2 L/day.
Blood tests show impaired renal function with serum
sodium 138 mmol/L, potassium 3.8 mmol/L, urea
8.2 mmol/L and creatinine 110 mmol/L. Urine sodium
measured 8 mmol/L. Which of the following treatments
should be recommended?
A. Increased existing fluid intake further aiming for
urine sodium >20 mmol/L
B. Limit existing oral fluid intake to <750 mL/day
and add 1500 mL/day of oral rehydration solution
with sodium content of 120 mmol/L sodium
5
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TRAINING MATTERS
C. Limit existing fluid intake to <1000 mL/day and
add 1000 mL/day of oral rehydration solution with
a sodium concentration of 90 mmol/L sodium
D. Institute long-term parenteral saline supple-
mentation
E. None of the above
Answer 2C. This patient has become dehydrated as a
consequence of mismanagement of his oral fluid intake.
He has developed mild renal impairment and has a low
urinary sodium suggesting he is sodium deplete.
Increasing existing hypotonic fluid intake will exacerbate
the problem further due to his jejunostomy. With the
length of residual small bowel, he should not require
long-term parenteral fluids. Restriction of hypotonic and
hypertonic fluids to less than 1000 mL/day and institution
of an oral rehydration solution to be sipped through the
day is required. A concentration of at least 90 mmol/L
sodium is required. Concentrations of >90 mmol/L of
sodium are poorly tolerated and are not necessary.
3. A 26-year-old female presents seeking dietary advice for
management of HOS. She has a jejunostomy following the
resection of a desmoid tumour involving the small intes-
tine. Her current Body Mass Index is 20 kg/m2. Which of
the following dietary adaptations should be advised?
A. Low fat, high carbohydrate, low fibre diet
B. Low fat, high carbohydrate, high fibre diet
C. High fat, low carbohydrate, low fibre diet
D. Addition of elemental sip feed in addition to the
patient’s existing diet
E. None of the above
Answer 3E. Patients with a jejunostomy, absorb a con-
stant proportion of the nitrogen, energy and fat from their
diet. In the past, low-fat diets were recommended to
reduce steatorrhoea. However, this makes reaching the
increased calorie requirements associated with HOS
(approximately 30% increase, total intake 45–55 kcal/kg/
day) difficult to achieve, and studies show that this does
not significantly reduce stoma output. Therefore, high
intakes of around 30–40% of energy from fat are recom-
mended. Carbohydrate intake should remain high but it is
generally accepted that a diet low in insoluble fibre (eg,
avoiding nuts, seeds, vegetable skins) is helpful in reducing
stoma output. Elemental diets cause the feed to be hyper-
osmolar and usually contain little sodium, potentially
increasing the losses of water and sodium from the stoma.
4. A 42-year-old male patient begins to experience an
increase in stoma output with a volume exceeding 2 L/
24 h, 1 week after colectomy with ileostomy formation for
Crohn’s disease. The pain around his stoma, which was
settling has now started to worsen. Investigations show a
rising c-reactive protein (CRP) and falling albumin. Which
of the following is the most likely cause of the problem?
A. Bile salt malabsorption
B. Peristomal abscess
6 Mountford CG, et al. Frontline Gastroenterology 2013;0:1–7. doi:10.1136/flgastro-2013-100375
C. Recurrent Crohn’s disease
D. Clostridium Difficile infection
E. Anatomical SBS
Answer 4B. Bile salt malabsorption only occurs if the
colon is in continuity. It is early in the postoperative period
for recurrent Crohn’s to be a cause of HOS. Infection is the
most likely cause of this picture of HOS with rising CRP
and falling albumin and in the context of peristomal ten-
derness a peristomal abscess is the most likely cause.
5. Which one of the following statements is not asso-
ciated with the pathophysiology of HOS?
A. Functional jejunal adaptation may occur after an ileal
resection that leaves colon in situ due to low circulat-
ing levels of peptide YY and glucagon-like peptide 2
B. Approximately 4 L of endogenous secretions pass the
duodeno-jejunal junction daily in a healthy individual
C. Patients with a stoma sited less than 100 cm from
the duodenojejunal junction are likely to experi-
ence a higher stoma effluent volume than their
oral intake volume
D. Jejunal mucosa is highly permeable resulting in
rapid water and sodium fluxes, so the jejunal con-
tents become iso-osmolar
E. Within the ileum, sodium can be absorbed
against a concentration gradient and is not
coupled to glucose absorption
Answer 5A. High levels of peptide YY and glucagon-
like peptide 2 are associated with retained right colon
and are associated with reduced gastric emptying and
small bowel transit and functional jejunal adaptation.
6. Which one of the following is a contraindication for
intestinal transplant assessment in adults?
A. Intestinal failure-associated liver disease
B. Recurrent septic episodes
C. Partial loss of central venous access (limiting
access to three major sites)
D. Complete loss of central venous access
E. Desmoid tumour requiring extensive surgery
involving partial or complete evisceration
Answer 6D. Access to the central venous system is
considered necessary to undertake intestinal/multivisc-
eral transplantation. In particular, there may be a need
for postoperative renal dialysis, management of
complex sepsis and multiorgan failure, administration
of drugs into large flow veins, rapid volume repletion
and invasive cardiovascular monitoring. It may also be
necessary to establish access above the diaphragm
when including a liver in a composite graft.
Transplantation may therefore be prevented by loss of
major venous access points. Therefore, a decision
regarding transplantation should be taken before
patients lose this opportunity. In general, it is consid-
ered that two of the standard (4× neck, 2× femoral)
major venous access points should be available with at
least one above the diaphragm if the liver is required.
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7. A 28-year-old female with a history of Crohn’s
disease and multiple small bowel resections with ile-
ostomy presents feeling faint, and complaining of
increased thirst and muscle cramps. On examination,
she is hypotensive with a systolic blood pressure of
95 mm Hg. The patient’s stoma output has increased
to 3.5 L in the past 24 h. She normally takes a litre of
oral rehydration solution (St Mark’s) each day. Which
of the following laboratory tests should be performed
to assess this patient’s hydration status?
A. Serum osmolality
B. Serum sodium
C. Random urinary sodium
D. Serum magnesium
E. Full blood count and inflammatory markers
Answer 7C. A random urinary sodium of less than
10 mmol/L will confirm sodium depletion. A urinary
sodium of >20 mmol/L should be the target of treat-
ment. Serum osmolality is not as useful a measure of
hydration status in this case. Measurement of serum
electrolytes is important, with subsequent replace-
ment as necessary, but do not provide adequate
information on hydration status alone.
8. A 60-year-old patient on home parenteral nutrition,
with a history of jejunostomy formation following
ischaemic bowel injury, attends the nutrition clinic.
The patient is keen to clarify what potential complica-
tions may be associated with his condition. Which of
the following is a potential complication that they
should be made aware of?
A. Increased risk of gallstones
B. Social difficulties associated with managing HOS
C. Fat-soluble vitamin deficiencies
D. Vitamin B12 deficiency
E. All of the above
Answer 8E. Patients with a jejunostomy are at risk of
all the complications listed. These should be moni-
tored for and where problems identified a manage-
ment plan out in place to address them.
Contributors CGM devised the idea and drafted the
manuscript. DMM and NPT provided additional ideas and
review. CGM, DMM and NPT all contributed to the
subsequent revision to produce the final version.
Competing interests None.
Provenance and peer review Not commissioned; externally
peer reviewed.
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 Downloaded from http://fg.bmj.com/ on February 24, 2015 - Published by group.bmj.com

A practical approach to the management of

high-output stoma
Christopher G Mountford, Derek M Manas and Nicholas P Thompson

Frontline Gastroenterol published online October 31, 2013

Updated information and services can be found at:

http://fg.bmj.com/content/early/2013/10/31/flgastro-2013-100375

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References This article cites 18 articles, 7 of which you can access for free at:
http://fg.bmj.com/content/early/2013/10/31/flgastro-2013-100375
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