The ‘stoma output’ is defined by the amount of faecal waste that is removed through the stoma. Usually the volume should be between 400-800mL per 24 hours.1 A high output stoma is above 1000mL a day, and is usually consists of very watery stool that requires emptying 8-10 times a day.2 

The constancy of stoma output can range from liquid to pasty depending on a patients diet, medications and other factors, and is usually emptied 5-8 times a day. [ostomy.org, ileostomy guide] 

 

HIGH STOMA OUTPUT

If it is too high the volume of output may need to be controlled by pharmacological intervention, and fluid and diet adaptations. If a patient is taking any medication that increases output such as laxatives and prokinetics then these should be stopped immediately. If the problem continues then medications that reduce gut motility and reduce gastric secretions may need to be prescribed. Medication containing sorbitol should be avoided in stoma patients due to its laxative effects. 

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Anti-diarrhoeal drugs - The most commonly used anti-motility drugs are the opioid agonist’s loperamide and codeine. They both act on the µ-receptors in the bowel to reduce peristalsis, and are taken about 30 minutes before meals and bedtime. 

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Loperamide off-label dose for reducing output: 8mg tablets four times a day. Higher doses are sometimes needed.

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Codeine dose for reducing stoma output: 15-30mg tablets four times a day. Max 240mg in 24h.

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f loperamide alone is not achieving the require effect, then codeine may be added into the therapy, usually at a dose similar to analgesia. Codeine can cause addiction, and also a tolerance may building up so careful patient monitoring is required. 

 

Anti-secretory drugs - After a colostomy or ileostomy gastric acid secretions often increase due to the negative feedback mechanisms that control acid production being disrupted. This can cause stoma output to increase, so reducing the gastric acid secretions if often necessary. The most common drugs used to achieve this are proton pump inhibitors and somatostatin analogues. 

Omeprazole is the PPI of choice, but patients who have had extensive small bowel surgery may not fully respond to this drug, due to the fact it is absorbed in the upper sections of the small intestine. 

Other drugs that may be used are the analogues of the hormone somatostatin; octreotide and lanreotide. They inhibit gastrin which in turn reduces gastric acid production. Octreotide is more commonly prescribed, and is done so off-label for stoma patients.

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Omeprazole high dose: 40mg tablets twice a day.

Octreotide off-label dose: 50-100mg three times a day, by subcutaneous injection.

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Oral rehydration - Patients with a high output commonly suffer from dehydration, but the fluid replacement to counter this is often managed incorrectly. If hypotonic fluids (such as water, tea, and coffee) are drunk in excess in high output then this may lead to sodium depletion and dehydration. Hypotonic fluids should therefore be limiting to approximately 500mL per day, and the other 1000mL drunk should consist of an oral rehydration solution. The glucose in ORS enables the intestine to more efficiently absorb the fluid and salts, rehydrating the patient more effectively than would be possible otherwise.3 ORS that can be used include St Mark’s solution, and Dioralyte “double strength” solution, and both can be prepared every morning with 1L of water and kept in the fridge, which is convenient for patients needing to drink them throughout the day.

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Dioralyte “double strength” solution:

Contains 10 sachets.

Ingredients per litre: 120mmol sodium, 40mmol potassium, 120mmol chloride, 180mmol glucose, 20mmol citrate.

 

St Mark’s solution:

Contains 20g glucose, 2.5g sodium bicarbonate, 3.5g sodium chloride.

Ingredients per litre: 90mmol sodium, 60mmol potassium, 111mmol glucose, 30mmol bicarbonate.

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LOW STOMA OUTPUT

It is also possible for a patient to have a low/absent output, and constipation. This can be caused by drugs that decrease motility, diet, blockages and also surgery recovery complications such as ‘post-operative ileus, which inhibits the passage of gastric contents through the bowel. The output can be increased by drug therapy, enteral feeding via a nasogastric tube to stimulate the bowel, and glycerol suppositories.

Pro-kinetic drugs such as metoclopramide, domperidone and erythromycin are the first choice, and are taken before meals.

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Metoclopramide dose: 10mg three times a day

Domperidone dose: 10mg three times a day

Erythromycin dose: 250mg three times a day.

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