High-Output Stoma After Small-Bowel Resections for Crohn's Disease

Stephen KK Tsao; Melanie Baker; Jeremy MD Nightingale

Disclosures

Nat Clin Pract Gastroenterol Hepatol. 2005;2(12):604-608. 

In This Article

Summary and The Case

Background: A 56-year-old Caucasian woman with a history of Crohn's disease and multiple bowel resections resulting in a loop jejunostomy was referred to our Nutritional Unit from a neighboring district general hospital for further management. She was first seen in October 2001, and initial assessment indicated that she was malnourished with fluid depletion, evidenced by the high volume of stomal fluid produced. There had been no sudden change in her medication, her Crohn's disease was quiescent and there was no evidence of any intra-abdominal sepsis. Despite a high calorific intake through her diet, she continued to lose weight.
Investigations Serum urea and electrolytes; magnesium; C-reactive protein; full blood count; urinary spot sodium; anthropometric measurements.
Diagnosis High-output stoma with malabsorption as a consequence of repeated small-bowel surgery.
Management The patient was treated with oral hypotonic fluid restriction (0.5 l/day), 2 l of oral glucose-saline solution per day, high-dose oral antimotility agents (loperamide and codeine phosphate), a proton-pump inhibitor (omeprazole) and oral magnesium replacement. A year later, the patient's loop jejunostomy was closed and an end ileostomy fashioned, bringing an additional 35 cm of small bowel into continuity; macronutrient absorption improved but her problem of dehydration was only slightly reduced. She was stabilized on a twice-weekly subcutaneous magnesium and saline infusion and daily oral 1α-hydroxycholecalciferol.

A 56-year-old Caucasian woman with problems of dehydration, hypomagnesemia and weight loss, due to a large stomal output (emptying bag 8-10 times/day), was referred to our Nutritional Unit from a neighboring district general hospital for further assessment in October 2001. She had undergone four operations for Crohn's disease over the preceding 25 years. The operations were a right hemicolectomy, two anastomotic resections and, 5 months prior to the consultation, a subtotal colectomy with ileorectal anastomosis and a defunctioning loop 'ileostomy' 120 cm from the duodenojejunal flexure. According to the treatment advice given several days before, she was taking loperamide (8 mg four times daily) to reduce her stomal output, and was having weekly intravenous magnesium replacement and Peptamen® (Nestlé Corporation, Switzerland) supplements.

At referral, the patient's BMI was 18.2 kg/m2. She had lost 20.9% of her body weight since the colectomy and looked thin; she was assessed as grade B according to subjective global assessment.[1] Her blood pressure was 120/75 mmHg lying and 104/69 mmHg standing. Her stomal output was 1,900 ml/day while taking a normal diet (2,600 kcal/day) and about 2 l of hypotonic fluid. Routine laboratory investigation revealed an elevated serum urea and creatinine, and decreased serum magnesium ( Table 1 ). Her random urine sodium was 10 mM.

A normal white-cell count, C-reactive protein, serum albumin and body temperature made sepsis unlikely. Endoscopic examination through her stoma showed quiescent Crohn's disease. The patient's dehydration, hypomagnesemia and undernutrition were attributed to having a relatively short length of remaining functioning small bowel. She was treated by restricting her intake of hypotonic fluid to 0.5 l daily and providing 2 l of glucose-saline solution/day, oral magnesium oxide tablets 12 mmol at night, omeprazole 40 mg once daily, continuation of loperamide at 8 mg four times daily, codeine phosphate 60 mg four times daily instead of cocodamol, and a high-calorie, high-protein diet, avoiding excessive fiber, with Peptamen® supplements.

The patient was reviewed 2 weeks later and had noticeable improvement in her stomal output (reduced and thickened) and hydration (no postural hypotension). Her BMI had increased to 19.9 kg/m2. Over the course of next few months, however, her compliance with the hypotonic fluid restriction was a problem, and she frequently needed additional intravenous saline and magnesium (1 l every 2-4 weeks). Her BMI had decreased to 17.3 kg/m2 in December 2001.

In order to improve her absorption of water, sodium and magnesium, the patient had further surgery 1 year later in our hospital. Her loop jejunostomy was closed and an end ileostomy fashioned giving her an additional 35 cm of small bowel. She had 7 days of supplemental parenteral nutrition preoperatively, followed by 3 months of nasogastric feeding with extra sodium chloride added to the feed postoperatively. Over the course of the next 12 months her BMI increased to 20.9 kg/m2, but she still had fluid depletion and hypomagnesemia despite taking 24 mmol/day of magnesium oxide. She was commenced on twice-weekly home subcutaneous saline (1 l) and magnesium (4 mM) infusion, together with the addition of oral 1α-hydroxycholecalciferol (500 ng/day). On this regimen she maintained her hydration and serum magnesium levels.

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