How to manage a high-output stoma

Frontline Gastroenterology ◽

10.1136/flgastro-2018-101108 ◽

2021 ◽

pp. flgastro-2018-101108

Author(s):

Jeremy M D Nightingale

Keyword(s):

Small Bowel ◽

Enterocutaneous Fistula ◽

Fluid Management ◽

High Dose ◽

Short Bowel ◽

Intestinal Length ◽

Proximal Small Bowel ◽

Parenteral Support ◽

Slow Transit ◽

High Output

A high-output stoma (HOS) or fistula is when small bowel output causes water, sodium and often magnesium depletion. This tends to occur when the output is >1.5 -2.0 L/24 hours though varies according to the amount of food/drink taken orally. An HOS occurs in up to 31% of small bowel stomas. A high-output enterocutaneous fistula may, if from the proximal small bowel, behave in the same way and its fluid management will be the same as for an HOS.The clinical assessment consists of excluding causes other than a short bowel and treating them (especially partial or intermittent obstruction). A contrast follow through study gives an approximate measurement of residual small intestinal length (if not known from surgery) and may show the quality of the remaining small bowel.If HOS is due to a short bowel, the first step is to rehydrate the patient so stopping severe thirst. When thirst has resolved and renal function returned to normal, oral hypotonic fluid is restricted and a glucose-saline solution is sipped. Medication to slow transit (loperamide often in high dose) or to reduce secretions (omeprazole for gastric acid) may be helpful. Subcutaneous fluid (usually saline with added magnesium) may be given before intravenous fluids though can take 10–12 hours to infuse. Generally parenteral support is needed when less than 100 cm of functioning jejunum remains. If there is defunctioned bowel in situ, consideration should be given to bringing it back into continuity.

Download Full-text

The medical management of intestinal failure: methods to reduce the severity

Proceedings of The Nutrition Society ◽

10.1079/pns2003283 ◽

2003 ◽

Vol 62 (3) ◽

pp. 703-710 ◽

Cited By ~ 52

Author(s):

Jeremy M. D. Nightingale

Keyword(s):

Small Bowel ◽

Enterocutaneous Fistula ◽

Intestinal Failure ◽

Bacterial Overgrowth ◽

Oral Intake ◽

Renal Stones ◽

High Dose Chemotherapy ◽

High Dose ◽

Proximal Small Bowel ◽

Intestinal Pseudo Obstruction

A new definition of intestinal failure is of reduced intestinal absorption so that macronutrient and/or water and electrolyte supplements are needed to maintain health or growth. Severe intestinal failure is when parenteral nutrition and/or fluid are needed and mild intestinal failure is when oral supplements or dietary modification suffice. Treatment aims to reduce the severity of intestinal failure. In the peri-operative period avoiding the administration of excessive amounts of intravenous saline (9 g NaCl/l) may prevent a prolonged ileus. Patients with intermittent bowel obstruction may be managed with a liquid or low-residue diet. Patients with a distal bowel entero-cutaneous fistula may be managed with an enteral feed absorbed by the proximal small bowel while no oral intake may be needed for a proximal bowel enterocutaneous fistula. Patients undergoing high-dose chemotherapy can usually tolerate jejunal feeding. Rotating antibiotic courses may reduce small bowel bacterial overgrowth in patients with chronic intestinal pseudo-obstruction. Restricting oral hypotonic fluids, sipping a glucose-saline solution (Na concentration of 90–120 mmol/l) and taking anti-diarrhoeal or anti-secretory drugs, reduces the high output from a jejunostomy. This treatment allows most patients with a jejunostomy and >1 m functioning jejunum remaining to manage without parenteral support. Patients with a short bowel and a colon should consume a diet high in polysaccharides, as these compounds are fermented in the colon, and low in oxalate, as 25% of the oxalate will develop as calcium oxalate renal stones. Growth factors normally produced by the colon (e.g. glucagon-like peptide-2) to induce structural jejunal adaptation have been given in high doses to patients with a jejunostomy and do marginally increase the daily energy absorption.

Download Full-text

Pediatric Short Bowel Syndrome: Predicting Four-Year Outcome after Massive Neonatal Resection

European Journal of Pediatric Surgery ◽

10.1055/s-0037-1604113 ◽

2017 ◽

Vol 28 (05) ◽

pp. 455-463 ◽

Cited By ~ 6

Author(s):

Teresa Capriati ◽

Daniela Giorgio ◽

Fabio Fusaro ◽

Manila Candusso ◽

Paolo Schingo ◽

...

Keyword(s):

Small Bowel ◽

Short Bowel Syndrome ◽

Intestinal Adaptation ◽

Bloodstream Infections ◽

Small Bowel Resection ◽

Strongly Correlated ◽

Small Bowel Length ◽

Short Bowel ◽

Intestinal Length ◽

End Stage

Objectives The aim of this study was to ascertain predictors of survival, liver disease (LD), and enteral autonomy 48 months after resection in neonatal short bowel syndrome (SBS) patients with residual small bowel length (SBL) ≤40 cm. Patients and Methods Medical records of all SBS patients followed up between 1996 and 2016 were retrospectively reviewed. Survival rate, prevalence of LD, and of enteral autonomy were evaluated. Results Forty-seven patients were included, and 43 were still alive at the end of the study period, with cumulative 48-month survival of 91.5%. Twenty-one (45%) patients developed LD, all within the first 6 months. On the final follow-up visit, three (6%) patients were still jaundiced and progressed toward end-stage LD. LD prevalence was higher in patients with recurrent bloodstream infections (odds ratio [OR] 5.4, 95% confidence interval [CI] 1.5–19.3). Of the 43 surviving patients, 22 (51%) had enteral autonomy 48 months after resection. The probability of weaning off parenteral nutrition (PN) was strongly correlated with the remaining SBL. Conclusion Survival of patients who have undergone neonatal massive small bowel resection has improved in recent years. Multidisciplinary strategies can improve the course of LD, but not the probability of weaning off PN, which seems to be strongly dependent on the anatomical profile of residual bowel. Therefore, the primary surgical approach should be as conservative as possible to gain even small amounts of intestinal length, which may be crucial in promoting intestinal adaptation.

Download Full-text

Bishop-Koop jejunostomy in an adult following proximal small bowel anastomotic breakdown

BMJ Case Reports ◽

10.1136/bcr-2018-227519 ◽

2018 ◽

Vol 11 (1) ◽

pp. e227519 ◽

Cited By ~ 1

Author(s):

Richard Alexander Dickson-Lowe ◽

Zandri Pienaar ◽

Johannes Jacobus Petrus Buitendag ◽

George Oosthuizen

Keyword(s):

Small Bowel ◽

Literature Search ◽

Bowel Injury ◽

Alternative Methods ◽

Rural Setting ◽

Small Bowel Injury ◽

Proximal Small Bowel ◽

Apple Peel ◽

Anastomotic Breakdown ◽

High Output

This case involves a proximal penetrating small bowel injury and the use of a Bishop-Koop anastomosis in a 33-year-old man. This case highlights the use of alternative methods used to prevent a proximal small bowel stoma in a rural setting. The Bishop-Koop anastomosis was originally designed for neonates in cases of intestinal anomalies such as atresia, volvulus and apple-peel syndrome. A literature search for the use of the Bishop-Koop anastomosis in adults, although scanty, is included in this article. We believe this article will benefit readers and that this method may be considered in breakdown of proximal small bowel injuries, to prevent a high-output stoma.

Download Full-text

The importance of a holistic approach to stoma care: A case review

WCET Journal ◽

10.33235/wcet.39.1.23-32 ◽

2019 ◽

pp. 23-32

Author(s):

Melanie C Perez

Keyword(s):

Ileal Conduit ◽

Enterocutaneous Fistula ◽

Foley Catheter ◽

Holistic Approach ◽

Comprehensive Care ◽

Case Review ◽

High Output ◽

Stoma Care

This case review discusses the importance of providing a holistic approach to the care of a patient with two stomas and an enterocutaneous fistula. In this case, the stomas and fistula significantly affected the patient; not just physically but emotionally and socially. The different challenges that arose in pouching a high-output ileostomy, enterocutaneous fistula and ileal conduit with Foley catheter in situ are explored. It also delves into the various options for discharging a patient with complex ostomy complications requiring different needs and resources. Finally, it aims to highlight the therapeutic comprehensive care the stomal therapy nurse provided to the patient and their family.

Download Full-text

Small-bowel perforation after preoperative high-dose-rate intraluminal brachytherapy for rectal carcinoma.

American Journal of Roentgenology ◽

10.2214/ajr.159.1.1609709 ◽

1992 ◽

Vol 159 (1) ◽

pp. 224-224

Author(s):

H Yanagi ◽

M Kusunoki ◽

N Kamikonya

Keyword(s):

Small Bowel ◽

Dose Rate ◽

Rectal Carcinoma ◽

Bowel Perforation ◽

High Dose Rate ◽

High Dose ◽

Small Bowel Perforation ◽

Intraluminal Brachytherapy

Download Full-text

Dosimetric Comparison between High Dose Rate Brachytherapy Boost and Volumetric Arc Therapy Boost in Locally Advanced Cancer Cervix

Asian Journal of Oncology ◽

10.1055/s-0041-1729480 ◽

2021 ◽

Vol 07 (02) ◽

pp. 085-088

Author(s):

Hanady Hegazy ◽

Neamat Hegazy ◽

Maher Soliman ◽

Amr Elsaid

Keyword(s):

Small Bowel ◽

Dose Rate ◽

Advanced Cancer ◽

Locally Advanced ◽

Target Volume ◽

High Dose Rate ◽

High Dose ◽

Cancer Cervix ◽

Arc Therapy ◽

Locally Advanced Cancer

AbstractConcurrent chemoradiotherapy is considered the standard treatment for the locally advanced cancer cervix (LACC). Radiotherapy is commonly administered by a three-dimensional conformal radiotherapy (3DCRT) approach followed by brachytherapy (BT). High dose rate (HDR) BT is commonly administered; however, several drawbacks exist including invasive technique, pain, requirement of anesthesia, and operative risks. We assessed the dosimetric difference between the HDR BT and the volumetric modulated arc therapy (VMAT) boost in those patients. Ten patients were selected retrospectively with LACC and all received whole pelvis radiotherapy followed by BT boost of 7 Gy in three fractions. The computed tomography (CT) image was transferred to the Varian system for the VMAT plan while the one with the applicator was transferred to the Sagi planning system and the high-risk clinical target volume (HR-CTV), bladder, rectum, sigmoid, and small bowel were delineate with a margin of 5 mm were added to the CTV to create the planning target volume (PTV). The D90 for the PTV in VMAT boost was lower than received by the HR-CTV in the BT boost. Mean volume of the PTV was higher than that of the HR-CTV. The D2cc was higher in VMAT for bladder, sigmoid, and rectum while the D2cc for the small bowel in BT was higher compared with the VMAT. The VMAT is an option that exists for patients who refuse BT or cannot tolerate it, or in case of nonavailability of BT or a nonworking machine.

Download Full-text

Measurement of hepatic insulin sensitivity early after the bypass of the proximal small bowel in humans

Obesity Science & Practice ◽

10.1002/osp4.76 ◽

2016 ◽

Vol 3 (1) ◽

pp. 95-98 ◽

Cited By ~ 2

Author(s):

A. D. Miras ◽

R. Herring ◽

A. Vusirikala ◽

F. Shojaee‐Moradi ◽

N. C. Jackson ◽

...

Keyword(s):

Insulin Sensitivity ◽

Small Bowel ◽

Hepatic Insulin Sensitivity ◽

Proximal Small Bowel

Download Full-text

1074 Gallstone Ileus: Two Decades After Cholecystectomy

British Journal of Surgery ◽

10.1093/bjs/znab259.358 ◽

2021 ◽

Vol 108 (Supplement_6) ◽

Author(s):

K Matwala ◽

M R Iqbal ◽

T Shakir ◽

D W Chicken

Keyword(s):

Small Bowel ◽

Bowel Obstruction ◽

Rare Complication ◽

Open Cholecystectomy ◽

Gallstone Ileus ◽

Proximal Small Bowel ◽

Solid Diet ◽

History Of ◽

Ileocaecal Junction ◽

Tomography Scan

Abstract Introduction Gallstone ileus is a rare complication of gallstones that occurs in 1%-4% of all cases of bowel obstruction. We present a surprising case of gallstone ileus causing small bowel obstruction 19 years after open cholecystectomy. Case Report A 77-year-old male presented with a 3-day history of abdominal pain, 4 episodes of vomiting and absolute constipation. He had a surgical background of an open cholecystectomy and open appendicectomy 19 years and 45 years ago respectively. Medically, he had well-controlled hypertension and experienced a TIA 5 years prior. Computed Tomography Scan of the abdomen and pelvis revealed features consistent with an obstructing, heterogenous opacity in the distal small bowel without pneumobilia. The patient subsequently underwent diagnostic laparoscopy. Intraoperatively, an obstructing gallstone, measuring 4 cm, was found 50cm proximal to the ileocaecal junction, with dilatation of the proximal small bowel and distal collapse. Enterotomy and removal of the stone was done. Post-operatively, this gentleman recovered without complications and was discharged home two days later after being able to tolerate a solid diet. Conclusions This is the second reported case of gallstone ileus in a patient with previous cholecystectomy about two decades ago, according to our literature search. Although extremely rare, absence of the gallbladder does not exclude the possibility of gallstone ileus.

Download Full-text

Small intestinal motility in fasted and postprandial states: effect of transient vagosympathetic blockade

AJP Gastrointestinal and Liver Physiology ◽

10.1152/ajpgi.1987.252.3.g301 ◽

1987 ◽

Vol 252 (3) ◽

pp. G301-G308 ◽

Cited By ~ 4

Author(s):

S. A. Chung ◽

N. E. Diamant

Keyword(s):

Small Bowel ◽

Intestinal Motility ◽

Gastric Fundus ◽

Phase Iii ◽

Entire Small Bowel ◽

Vagal Blockade ◽

Small Intestinal Motility ◽

Proximal Small Bowel ◽

Small Intestinal ◽

Gastric Contractions

We investigated vagal control of the migrating myoelectric complex (MMC) and postprandial pattern of the canine small intestine. Gastric and small intestinal motility were monitored in six conscious dogs. The vagosympathetic nerves, previously isolated in bilateral skin loops, were blocked by cooling. To feed, a meat-based liquid food was infused by tube into the gastric fundus. MMC phases I, II, III, and IV were observed in the fasted state. On feeding, the fed pattern appeared quickly in the proximal small bowel but was delayed distally. Vagal blockade abolished all gastric contractions and spiking activity as well as the small bowel fed pattern. During vagal blockade, the small bowel exhibited MMC-like migrating bursts of spikes in both the fasted and fed states. The migration and cycling of these bursts were not significantly different from the MMC, but the duodenal and jejunal phase II was absent or shortened. On termination of vagal blockade, normal fasting or fed activity reappeared but with a delay in the fed pattern distally. We conclude: the ileum is the least sensitive to vagal blockade; the fasting vagal influence is exerted primarily on phases I and II of the duodenal and jejunal MMC; the fed pattern throughout the entire small bowel is normally dependent upon vagal integrity; the phase III-like bursts of activity seen during vagal blockade likely represents the intrinsic small bowel MMC, which is vagally independent.

Download Full-text