Editing Stomal complications (section)

== '''Ileostomy-specific''' ==

=== Dehydration ===

=== '''High ostomy     output''' ===

** '''Background:'''      
*** A fully-adapted end       ileostomy has an output of 500mL/24 hours. Initially post-op, it is       usually 1000-1800mL/24 hrs, but usually comes down after a few days.
*** High-output stoma defined       as >1.5L per day
** '''Pathophysiology'''
*** Coupled absorption of       sodium and glucose in jejunum via SGLT1 symporter
**** If chyme is hypotonic,        reduced ability to absorb glucose given sodium is working against a        concentration gradient, so glucose will remain in lumen, leading to        osmotic/secretory 'diarrhoea'
**** If chyme is isotonic        (>90mmol/L sodium), glucose and sodium can both be absorbed from        lumen, and the water will follow, thus reducing ileostomy output
***
*** Standard sport drinks are       not suitable - Gatorade only has 500mg sodium but 60g glucose per litre       (23mmol/L sodium) - it may be called 'isotonic', but doesn't work well       for optimising intestinal absorption of fluid because it's lower in salt       and higher in sugar than St Mark's
*** Tea, coffee, juice all       count as free water
*** To improve the taste of St       Mark's:
**** Drink chilled
**** Turn into ice cubes
**** Drink through a straw
**** Add a little juice/soda
** '''Risk      factors:'''
*** Proximal stoma
*** Intra-abdominal sepsis
*** Following resolution of       post-op ileus or SBO
** '''Classification'''
*** 1-1.5L/24 hours: 'pre-high'
*** 1.5-2L: mild high
*** 2-3L: moderate high
*** >3L: severe high
** '''Evaluation''' of suspected developing      high stoma output
*** Observe stoma output for 48       hours before intervening
*** Rule out other causes:
**** Intra-abdominal sepsis
**** Intermittent obstruction
**** Infectious diarrhoea
**** Medications (prokinetics,        metformin)
*** MDT involvement
**** Stoma nurse
**** Dietician
**** Daily weights
**** Accurate fluid balance
**** Patient education
*** Urinary sodium levels can       be used to guide level of hydration - aim for <20mmol/L
** '''Management:'''      after 48 hours      of high output
*** Use a combination of       interventions to match the severity of the insult
*** Escalate to next level (add       interventions from that stage) if not seeing improvement
*** Always consider early stoma       reversal
*** For a new stoma, if unable to get control of outputs with moderate doses of stoppers (~10mg daily loperamide), ensure there are no contributing factors before increasing further - review medications, strongly consider CT to exclude partial obstruction/collections and stool PCR for infection 
*** Stage 1: Establish       stability
**** Pre-high
***** Stop free water
***** St Mark's solution for         total hydration needs
***** Oral electrolyte         replacements
***** Low-residue diet, with         thickening foods (starchy foods, soluble fibre including         Fybogel/psyllium husk/Metamucil; avoid insoluble fibre)
***** Low-dose loperamide - 2mg         QID
**** Mild high
***** Oral St Mark's up to         maximum of 1L per day. No water.
***** Add IV hydration and IV         electrolytes
***** Loperamide 4mg QID (open         capsules, have 30 minutes prior to meals)
***** Pantoprazole 40mg BD
**** Moderate high
***** Loperamide 8mg QID
***** Codeine 15mg TDS
**** Severe high
***** Loperamide 12mg QID
***** Codeine 30mg TDS
***** Consider         diphenoxylate/atropine (Lomotil) for additional anti-motility
***** Consider TPN if concerns         for malnutrition - high stoma output can compromise absorption
***** Consider chyme reinfusion         pump
*** Stage 2: stability and       transition to discharge
**** Home when:
***** Self-managing
***** Stable output, ideally         <1L
***** Nutritionally ok
*** Stage 3: long-term
**** Link in with dietitian
**** Long-term nutritional        deficits in B12, zinc, selenium, and vitamins A, D, E, and K can result

'''Antimotility agents used for high-output fistulas'''
{| class="wikitable"
|'''Drug'''
|'''Initial dose'''
|'''Route'''
|'''Frequency'''
|'''Titration'''
|'''Max dose'''
|'''Cost*'''
|'''Special considerations'''
|-
|Loperamide
|4 mg
|PO
|Three times daily  with meals or every 6 hours with enteral nutrition
|By 2 mg
|16 mg/day
|$
|Avoid liquid due  to propylene glycol content
|-
|Diphenoxylate/atropine  (Lomotil)
|2.5  mg/0.025 mg (1 tablet)
|PO
|Three times daily  with meals or every 6 hours with enteral nutrition
|By 1 tablet
|2  tablets four times daily (20 mg diphenoxylate)
|$$
|Avoid liquid  formulation due to sorbitol content
|-
|Pantoprazole
|40 mg
|IV
|Twice daily
|None
|40 mg twice daily
|$$$
|Discontinue as  soon as feasible
|-
|Codeine
|15 mg
|PO
|Three times daily  with meals, up to four times daily
|By 15 mg
|45 mg four times  daily
|$$
|Monitor for CNS  effects
|-
|Octreotide
|100 mcg
|SC
|Three times daily
|None
|None
|$$$
|Discontinue if  output not decreased after 3 to 5 days
|-
|Clonidine
|0.3 mg
|Transdermal
|Every 7 days
|None
|0.3 mg every 7  days
|$$$$
|Monitor HR and BP
|}

=== Food blockage ===

=== Drug malabsorption ===