Management of High-Output Fecal Stomas
One of the greatest challenges ostomy care clinicians face is the management of high-output fecal stomas. Not only are they frustrating for the clinician, but they also create significant quality-of-life issues for the patient. For example, daily containment of 2,400 mL of fecal output in a traditionally sized ostomy pouch requires constant emptying, odor management, peristomal skin protection, and concern regarding large volumes of nighttime stool while the patient sleeps.
The most common type of high-output fecal stoma is a jejunostomy — an opening into the jejunum, the midportion of the small intestine.1 The jejunum is a major organ for nutrient absorption (most fats, proteins, vitamins, and carbohydrates not already absorbed in the stomach and duodenum).2 Nutrient absorption is assisted by folds, called plicae circulares, of the mucosal and submucosal layers of the jejunum. Interestingly, plicae circulares are absent in the terminal ileum. The mucosal layer also contains villi — fingerlike projections covered with absorptive cells with extensions known as microvilli. Together, the plicae circulares, villi, and microvilli increase the absorptive surface of the jejunum 600-fold.3 A large amount of digestive enzymes also is secreted in the jejunum, further aiding in digestion.
Patients with a jejunostomy are typically managed in a manner similar to those with short bowel syndrome or short gut. A short bowel is defined as insufficient length of functioning gut to allow adequate absorption needed to maintain health.4 If <200 cm of small bowel remain, adequate absorption is unlikely. Patients with a jejunostomy can be classified as “net absorbers” or “net secretors.” Net secretors usually have <100 cm residual jejunum and lose more water from the stoma than can be taken orally. These patients experience increased output in the daytime with food intake and less output at night.4 Net absorbers take more water and sodium from their diet than they can consume orally and can be managed with oral sodium and water supplements, negating the need for parenteral fluids.4 A clinical assessment of a patient with a short bowel includes measurement of the small bowel length and ascertaining water, sodium, magnesium, and nutritional status.
A jejunostomy may be performed for many reasons, including superior artery thrombosis, Crohn’s disease, and radiation enteritis. Jejunal output is usually watery, clear, and dark green and can exceed 2,400 mL every 24 hours. Each liter of jejunostomy fluid contains about 100 mmol/L1 of sodium.4 Due to the high liquid fecal output and short transit time, patients with a jejunostomy are at high risk for dehydration, fluid and electrolyte imbalance, and malnutrition. Many patients are maintained on parenteral nutrition, which can help reduce stomal output.
However managed, patients with a jejunostomy have many ostomy-related social problems including severe thirst, sodium and water depletion, and high fecal output management. It is common to recommend oral hypotonic fluids to quench patients’ thirst, but this causes large sodium losses through the stoma.4 Nightengale4 recommends restriction of oral hypotonic fluids (water, tea, fruit juices, alcohol, or dilute salt solutions) and increased oral intake of glucose-saline replacement solutions (oral rehydration therapy). For patients who are able to eat, gut-slowing medications may be prescribed to lengthen transit time as well as to assist with rapid gastric emptying that can lead to malabsorption.5
Quality-of-life issues are related to diarrhea (high stomal output), odor, dehydration, food restrictions, dependency on treatment (ie, parenteral nutrition), incomplete absorption of medications that may require regular intramuscular injections, and vitamin deficiency.
Management of high-volume output is problematic. The natural choice is to select a larger pouch with greater capacity. However, it is important to realize that liquid output can be heavy. Today, a variety of high-output pouching systems designed to address special needs are available. Before the development of these pouching systems, irrigation sleeves often were used. However, due to their length and the weight of the output, it was difficult for patients to wear clothing or even ambulate without disrupting the seal between the skin barrier and the pouch. Traditional ostomy pouching systems have been connected to bedside drainage using large lumen oxygen tubing in cases where high output (averaging 3,200 mL per day) was thick.6 Changing a pouching system on a high-output stoma also is difficult because the effluent is continuous, copious, and explosive (especially if the patient is permitted to eat) and often requires the attention of two clinicians or other caregivers.
The corrosive effect of jejunal effluent and the potential for leakage and maceration make protecting the peristomal skin imperative. Extended-wear skin barriers, convexity, one-piece pouching systems, and cohesive seals may be helpful tools in maintaining peristomal skin integrity.
Clinicians must be aware of the myriad physical and psychological issues facing someone with a high-output stoma.
The Ostomy Files is made possible through the support of ConvaTec, a Bristol-Myers Squibb Company, Princeton, NJ.
This article was not subject to the Ostomy Wound Management peer-review process.