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

Treatment and Management

To detect dehydration, patients should be asked if they are thirsty or feel dry. Examination looks for dry mucous membrane, reduced skin turgor, postural systolic hypotension, a rapid fall in body weight and a reduction in urine volume. Levels of serum urea and creatinine might be raised, and magnesium levels low. A random urinary sodium concentration of <10 mM is a good indicator of sodium depletion. In general, a stomal output >2 l/day is likely to result in dehydration, and sodium and magnesium depletion.

Knowledge of the remaining small-bowel length can be used to predict the clinical outcome. This measurement is either done at surgery or from a small-bowel meal film using an opisometer.[6] In general, patients with a jejunostomy and less than 100 cm of remaining functioning small bowel are likely to need parenteral nutrition. For those with 100-200 cm, often an oral glucose-saline solution and nutrient drinks will suffice. Our patient's initial small-bowel length to the loop jejunostomy was 120 cm.

Monitoring during treatment includes daily measurement of body weight, fluid balance (including stomal effluent) and postural blood pressure. Serum magnesium, urea and creatinine levels and weekly random urinary sodium levels are the most important measures. The aim is to keep the urinary sodium concentration >20 mM and daily urinary volume >800 ml.

Current body weight and height, and usual weight in health, allow BMI and percentage weight loss to be calculated. Subjective global assessment is a more detailed initial assessment when a patient's history, symptoms and physical parameters are included. Anthropometric measurements are useful and provide a measure of muscle mass; however, these measurements are prone to interobserver variability.

Restrict Oral Fluids. It is a misconception that patients with high stomal output can quench their thirst by drinking large volumes of hypotonic solution (e.g. tea, coffee and fruit juice). As the jejunal mucosa is 'leaky', when a solution <90 mM is drunk, there will be a net efflux of sodium from serum into the bowel lumen. This process continues until the luminal sodium concentration reaches 90-100 mM. As more hypotonic fluid enters the jejunum, sodium and water losses through the stoma are greater.

For such patients it is often quicker and simpler to keep them 'nil by mouth' for 24 h, giving intravenous saline to reduce the stomal output and correct the dehydration. The next step is to restrict oral hypotonic fluids to <500 ml daily. The rest of the fluid requirement is made up of glucose-saline solution.[7]

Glucose-Saline Solution. Sodium absorption in the jejunum is coupled with glucose absorption; therefore, patients are advised to sip 1 l or more of a glucose-saline solution (sodium concentration 90-120 mM) throughout the day.[8] In this case the patient was encouraged to drink 2 l of glucose-saline solution daily.

Antimotility Drugs. Loperamide before meals, even at high doses, is preferred to codeine phosphate as it is nonaddictive, nonsedative and does not impair pancreaticobiliary secretions. Both are effective in reducing the weight and sodium content of the ileostomy output by 20-30%.[9] Because of the degree of our patient's stomal output, both loperamide and codeine phosphate were used in combination. Cocodamol should not be used because it contains inadequate amounts of codeine and was thus discontinued in our patient.

Antisecretory Drugs. Antisecretory drugs can cause a marked reduction (0.5-2.0 l/day) in stomal output in net secretor patients. The proton-pump inhibitor omeprazole at 40 mg/day is as effective as intravenous octreotide 50 µg twice daily, providing the patient has at least 50 cm of jejunum.[10]

Magnesium Supplements. The correction of sodium depletion can be the single most important factor in treating hypomagnesemia. Oral magnesium oxide can be given to a total of 12-24 mmol/day and does not appear to increase stomal output. This treatment is taken at night when intestinal transit is at its slowest, allowing more time for absorption. The patient took 12 mmol oral magnesium oxide at night.

Oral 1α-hydroxycholecalciferol can be given to increase both intestinal absorption (directly) and renal absorption (indirectly via parathyroid hormone) of magnesium. The dose of 0.25-9 µg daily is gradually increased (every 2-4 weeks at 0.25 µg increments) while ensuring that hypercalcemia does not occur.[11] Some patients might need regular intravenous or subcutaneous saline and magnesium infusions.

Nutritional Requirements. Specific dietary restrictions in jejunostomy patients haven't been shown to be of benefit; such patients need a large oral energy intake of a polymeric, iso-osmolar diet that is relatively high in fat and with added salt. Hyperphagia is encouraged to compensate for malabsorption. Additional oral sip-feed can be given. The osmolality of any feed is kept low (300 mOsm/kg) by using large molecules such as polysaccharides, protein and triglycerides, and extra sodium is added to give a concentration of 90-120 mM.[12,13] In patients with Crohn's disease, if obstructive symptoms are present, a low-residue diet is recommended. Peptamen® was chosen in this case mainly because of its low osmolality, which shouldn't worsen fluid and sodium loss through the stoma. Our patient supplemented her diet with four cartons of Peptamen® per day (giving 800 kcal).

Surgical Treatment. Despite adequate medical and nutritional therapy, our patient remained undernourished, and suffered from frequent fluid depletion and persistent hypomagnesemia. Her last operation was to close the loop jejunostomy and bring back an extra 35 cm of small bowel in the hope that it will increase absorption. She improved nutritionally but still remains dependent on regular subcutaneous saline and magnesium infusions.

In some specialized centers, surgical procedures that slow intestinal transit have been successful. One example is the construction of antiperistaltic segments (about 10 cm of small bowel is reversed), which act as 'physiologic valves' by causing retrograde peristalsis and disrupting the motility of proximal intestine. This technique has been reported to result in improvement in up to 80% of patients.[14] In some centers reconstructive surgery to lengthen the small bowel has been performed in children whereby the dilated remaining small bowel (diameter >4 cm) is divided longitudinally and anastomosed end to end.

There is no evidence of structural or functional adaptation in patients with jejunostomy. Glucagon-like peptide 2, a trophic growth factor, stimulates mucosal proliferation and is found at low levels in jejunostomy patients. When this molecule or an analog are injected daily into such patients, an increase in mucosal growth, in energy absorption (by 3.5%) and in body weight (of 1.2 kg) have been observed over a 35-day period, as well as an 11% reduction in stool weight.[15] Growth hormone is licensed for use in patients with short bowel in the US; however, the data from randomized double-blind placebo controlled trials are conflicting.

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