5/1/2020

Challenges for the Ostomate: The Science Behind

Maintaining Nutrition for Fecal and Urinary Diversions

Arlene A. Escuro, MS, RD, LD, CNSC, FAND

Advanced Practice II Dietitian
Digestive Disease and Surgery Institute
Cleveland Clinic, Cleveland, OHIO

CONFLICT OF INTEREST DISCLOSURE

I do not have any relevant relationships to disclose.

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LEARNER OUTCOME

 Understand the nutrition management principles involved

with each type of fecal and urinary diversions to plan and
implement appropriate interventions.

GI Tract

Anatomy
Duodenum (~30 cm in length)
 Loss of digestive enzymes
 Decreased absorption of
bile salts, pancreatic
enzymes and bicarbonate
 Steatorrhea and fat soluble
vitamin deficiencies

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Anatomy
Jejunum (~250 cm in length)- majority
of absorption occurs in the first 150 cm
 Malabsorption of nutrients, electrolytes
and vitamin/trace elements
 Osmotic diarrhea
 Dehydration
 Dependence on oral electrolyte
supplementation, enteral nutrition, oral
rehydration solution (ORS), parenteral
support
Ileum has the ability to take over functions
of the jejunum leading to adequate post-
adaptation absorption

Anatomy
Ileum (~350 cm in length)
 Rapid intestinal transit
 Malabsorption of nutrients,
electrolytes, vitamin and trace
elements
 Dehydration
 Bile salt wasting
 Calcium oxalate nephrolithiasis if
colon is present
Jejunum has a limited ability to
compensate for loss of the ileum

Anatomy
Colon (~150 cm in length)
 Malabsorption of
electrolytes
 Dehydration
 Rapid transit due to loss of
the ileal cecal valve (ICV),
Peptide YY and GLP-1 (“ileal
brake”)

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Assessing Anatomical Configuration

 Integrity of interrelated organs (i.e. liver, pancreas, and stomach)
 Review of surgical hx/operative notes/pathology reports
 Patient’s anatomy
 length of the small bowel
 presence or absence of the ileocecal valve
 presence of additional small bowel out of continuity
 amount of colon (in or out of continuity)
 presence of rectum and anus
 Imaging- CTE, Upper GI with SB follow through
 Quality of the residual bowel

Anatomical Impact on Fluid and Electrolyte Balance

Conditions Requiring Intestinal Alteration/Surgery

 Active inflammatory bowel disease (IBD)

 Complications post malabsorptive surgeries (Gastric Bypass,
Duodenal Switch, Gastric Sleeve, etc.)
 Radiation enteritis
 Gardner’s Syndrome/Familial Polyposis (FAP/desmoids)
 Ogilvie’s Syndrome and CIPO (chronic intestinal pseudo-
obstruction)

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ERAS:
Facts and Data for Perioperative Nutrition Screening

Enhanced Recovery After Surgery (ERAS)

Summary of Key Recommendations for Perioperative Nutrition Care

Nutrition Assessment
 Assessment and Evaluation by RD (registered dietitian)
 Develop nutrition care plan using medical, nutritional and
medication histories
 Review of lab data
 Review of patient’s GI anatomy
 Assess need for additional imaging
 Nutrition-focused physical examination
 Diagnose presence of malnutrition
 Referral to other disciplines
 Provide nutrition therapy/diet education

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Ileostomy
 Postop Diet Modification
 ERAS (Enhanced Recovery After
Surgery):
 Early PO diet advancement
 Oral nutrition
supplementation
 Oral rehydration solutions
(ORS)
 Encourage gum chewing
 Soft, fiber-controlled diet for
4-6 weeks
 Diet education before hospital
discharge

Early vs Traditional Diet Advancement

 Toledano et al (2019) compared postop feeding outcomes (time to

first flatus and time to first ostomy output) in patients who had
ileostomy and colostomy creation
 Retrospective, non-randomized design, 255 patients
 204 pts (80%) received early diet advancement (clear liquid or low
fiber diet on POD 0 or 1)
 51 pts (20%) received traditional diet advancement (clear liquid or
low fiber diet on POD 2 or later)
 Time to first flatus and ostomy output significantly shorter in the
Early compared with Traditional diet advancement

Ileostomy
Components of Postop diet Education (1:1, Video, Group)
 Soft, fiber-controlled (10-15 grams/d)
 Eat slowly, and chew foods to mashed potato consistency
 Consume 5-6 small meals daily
 Separate liquids from meals
 Avoid high sugar foods and fluids/ concentrated sweets
 Avoid foods, beverages, medications containing sugar alcohols
 Lactose is generally well tolerated, unless the patient is intolerant
 Provide liberal amounts of sodium in the diet, incorporate salty/starchy snacks
 Avoid alcohol and caffeine as they are GI stimulants increasing output
 Oral rehydration solutions/recipes
 Oral nutrition supplements (low sugar/high protein)
 High biological value protein (i.e. eggs) are encouraged

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Ileostomy
Nutrition after recovery from surgery and beyond
 Slowly begin to introduce new foods into diet (1 to 2 foods at
a time)
 Keep a food journal (to track foods that might be problematic)
 Role of Fiber: does it help or hurt?
 Increase ileostomy effluent viscosity
 Slow transit time
 Reduce water and micronutrient losses

Types of Fiber
Soluble Insoluble

Types Pectin Cellulose

Fructans Chitin
Inulin Some Hemicellulose
Some Hemicelluloses Hexoses
Psyllium Pentose
Mucilage Lignin
Guar gum Xanthan gum

Sources Oatmeal, Oat, Barley Whole wheat, Wheat, Barley

Legumes Legumes
Pulp of some fruits Skin of some fruits
Bananas Grapes

Benefits Fermented by colon Non fermentable in colon

Slows fecal transit time Speeds transit time
Forms a viscous gel Increase fecal volume

Common Fiber Supplements

Fiber Brand Name Soluble ?

Psyllium Metamucil Mostly (70/30)

Methylcellulose Citrucel Yes

Calcium Polycarbophil FiberCon Yes

Inulin Fiber Choice Yes

Wheat Dextrin Benefiber Yes

Wheat Bran N/A No

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Ileostomy
High Output Stoma (HOS)  Potential Causes
 Acute or chronic  IBD
 No agreed-upon definition  C. diff colitis
 1.2 L over 24 hours  MRSA enteritis
 2 L over 24 hours for 3  Intra-abdominal sepsis
consecutive days
 Partial or intermittent
 Increased risk for dehydration obstruction
and malnutrition
 <200 cm of residual SB
 Medication-related

Management of HOS (high output stoma)

Nutrition Care Plan
 Restriction of oral hypotonic and hypertonic fluids to 500
mL/day
 Replacement of depleted fluids and electrolytes
 Oral rehydration solution (ORS) at least 1 Liter/d to be sipped
throughout the day
 Nutrition support (TPN) and/or specialized IV fluids
 Pharmacologic management (antimotility medications)

Oral Rehydration Solutions (ORS)

 Developed by the World Health Organization (WHO) to improve
absorption of fluids and electrolytes
 Improve hydration
 ORS stimulates the glucose-sodium co- transporters to transfer fluids
across the intestinal mucosa to increase fluid absorption and decrease the
need for PN and fluid requirements
 ORS contains:
 90 mEq/L Na+
 20 gm/L glucose
 Non-ORS beverages (Isotonic, Na+ free fluids and hypertonic solutions)
should be avoided as they may induce dehydration through increased
enteric losses

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Commercially Available ORS

Solution Carbohydrate Sodium Osmolarity Company
(g/L) (mEq/L) (mOsm/L)
WHO Packet 20 90 330 Jianas Brother’s
Rehydralyte 25 75 310 Abbott
Nutrition
Drip Drop 33 60 235 Drip Drop
Hydration, PBC
Ceralyte 70 40 70 <260 CeraLyte
Pedialyte 25 45 250 Abbott
Nutrition
Parent’s Choice 20 45 262 Wal-Mart
Pediatric Stores
Electrolyte

Keys to Success with ORS

WHO WHY HOW
Motivated Patients Patients with Patient Support Needed
Understanding of
 Urine <1 L/24 hr  Hydration importance  Access to recipes and
 Stool/Ostomy >1 L/24  Combined therapies- purchasing information
hr ORS, diet and  Tools for mixing ORS
 Signs of dehydration medications  Equipment to monitor
 Multiple encounters for  Monitor, record weight hydration
dehydration and 24 – hour urine and  Sip, sip, sip throughout
 Can follow instructions stool/ostomy outputs the day, every day
explicitly
 Autonomous to adjust
volume based on urine
volume

End Jejunostomy
 Likely require Parenteral Nutrition (PN) and/or specialized IVFs
 Minimize oral intake to minimize ostomy output
 Single Starch diet protocol
 Indications:
 dependent on PN
 <90 cm of small bowel to an ostomy
 Prolonged ostomy outputs consistently >2.5 or 3 Liters/d

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Ileal Pouch Anal Anastomosis (IPAA)

Postoperative nutrition considerations (and
beyond):
 Vitamin B12 deficiency
 Decreased absorptive capacity
 Inadequate dietary intake
 Bacterial overgrowth
 Pouchitis
 Anemia and Iron deficiency
 Impaired absorption
 Decreased oral intake
 Increased requirements
 Blood loss
 Vitamin D deficiency
 Bile salt malabsorption
 Fluids and electrolytes
 Trace elements

IPAA Food-related Intolerances

Symptom Food

Increased stool output Nuts, corn, chocolate, milk, spicy foods,

alcohol

Increased flatulence Spicy foods, onions, milk, cabbage

Decreased stool consistency Beer, wine, spicy foods, cabbage, fruit

Perineal irritation Spicy foods, citrus fruits, nuts, seeds

Increased stool consistency Pasta, banana, potatoes, bread

Continent Ileostomy (K Pouch)

 rarely created
 potential advantage of improved
body image and self-esteem
 nutrition considerations:
 limit nuts, skins, popcorn,
seeds, cooked veggies with
hulls, fruit and vegetable
skins, whole spices even
AFTER 6 WEEKS
 undigested foods may
obstruct the valve
 surgical revisions are common

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Ileal Conduit (Urostomy)

Postoperative metabolic and nutrition considerations:

 Decreased bile salt and fat absorption
 Diarrhea
 Acid base abnormalities (metabolic acidosis)
 Electrolyte abnormalities
 Vitamin B12 deficiency
 Renal calculi

Factors that impact on medication absorption

 Type of ostomy formed
 Amount of SB remaining following resection
 Quality of remaining SB
 Nature and volume of stoma output
 Form in which medication is prescribed
 Intestinal content transit time

Medication administration in patients with ileostomy

 Avoid enteric-coated, sustained-release or slow-release medication

 Consider an alternative route to administer medication
 Avoid sorbitol or sugar alcohols (found in liquid preparations) due
to laxation effect
 Monitor effluent for remnants of undigested medication
 Patients should always inform medical provider that they have an
ileostomy
 Be aware of the impact of increased intestinal content transit time
has on medication absorption

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Pharmacology of Intestinal Failure

 Antidiarrheal
 Antisecretory
 Fat malabsorption
 Small Intestinal Bacterial Overgrowth (SIBO)

Antidiarrheals

Contracted Muscle
Direction of Food Movement

Food Bolus

Relaxed Muscle

Antidiarrheals
Name Class Typical Dose Maximum Dose
Loperamide Antidiarrheal 4-8 mg daily 16 mg/day
1-2 tablets four
times daily
Diphenoxylate Antidiarrheal 2.5-5 mg four times 20 mg/day
daily
Codeine Opioid 15-30 mg four 240 mg/day
times daily
Tincture of Opium Opioid 0.3-0.6 ml four
times daily

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Anti-secretory Agents

H2 blockers:
↓ Gastric acid producPon

Proton pump inhibitors:

↓ H+ producPon

•Mental status changes, headaches, flatulence

Antisecretory
 Proton Pump Inhibitors (PPI)
 Omeprazole, Esomeprazole, Pantoprazole, Lansoprazole
 Histamine 2 Receptor Antagonists
 Famotidine, Ranitidine, Cimetidine
 Somatostatin
 50-100 mcg three times daily
 Clonidine
 0.05-0.1 mg twice daily

Fat malabsorption
 Caused by many different mechanisms
 Decreased pancreatic enzymes
 Rapid intestinal transit
 Bile acid wasting

 Pancreatic enzymes provided with meals

 Dose based on lipase units (LU) and body weight in kilograms
 Adjusted based on clinical symptoms of fat malabsorption
 500- 2500 LU per kg of body weight per meal

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Enterohepatic Circulation of Bile

Ileal Resection < 100 cm

• Increased bile acids in

fecal water
• Cholestyramine

Ileal Resection > 100 cm

• Depleted pool
• Steatorrhea
• Malabsorption
Hoffman
Hoffman
AF, Poley
AF, Poley
JR. Gastroenterology
JR. Gastroenterology
1972;62:918-934
1972;62:918-
934

Choleretic diarrhea
 Bile salts reabsorbed in the terminal ileum
 Choleretic diarrhea after >100 cm terminal ileum resection with intact colon
 Bile acid sequestrants :
 Bind with unabsorbed bile salts
 Potential to worsen fat malabsorption and cause fat soluble vitamin deficiencies
 Can bind with other medications and minerals
Bile acid binding resins Dosage
Cholestytramine Powder: 2-4 g dose mixed with a liquid
up to 3x daily before a meal
Colestipol Powder: 5 g mixed with a liquid up to
4x daily
2 g tablet: 2-4 g up to 4x daily (max
dose 16 g/d)
Colesevelam Tablet or suspension: 1.25-3.75 g daily

Small Intestinal Bacterial Overgrowth (SIBO)

Causes: impaired peristalsis due to
Diagnosis
 Post surgical SB inflammation and
 Hydrogen breath testing
dilatation
 SB aspirate
 Loss of ileocecal valve (ICV)
 Loss of terminal ileum
Treatment
 Changes of adaptation
 Diet
Symptoms
 Probiotics
 Excessive gas, bloating
 Antibiotics
 Diarrhea/constipation
 Foamy/frothy stool
 Foul smelling stool or body odor
 Weight loss
 Nutrient deficiencies
 Fatigue

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SIBO: Probiotics
Probiotic* Active Ingredient Form Regimen
Align Bifidobacterium infantis Tablet 1-3 tabs/d
Culturelle L rhamnosus GG Tablet 1-2 tabs/d
Primal Defense Lactobacillus species, Tablet 1 tab/d
Bifidobacterium species
Activia-light Bifidobacterium lactis Yogurt 1-2 servings/d
DanActive Lactobacillus casei Yogurt 2 servings/d
VSL #3 Streptococcus thermophilus, Tablet, 1-3 packets/d
bifidobacterium, powder
lactobacillus
*When taking an antibiotic for SIBO, all probiotics should be taken 2 hours away
from antibiotic.

SIBO: Antibiotics
Antibiotics Regimen

Ciprofloxacin (Cipro) 500 mg BID

Metronidazole (Flagyl) 250 mg TID

Rifaximin (Xifaxan) 400 mg TID

Doxycycline (Doxy) 100 mg BID

Amoxicillin (Amoxi) 500 mg TID

Tetracycline (Terramycin) 250 mg 4x/d

Interprofessional Team Approach

 collaboration is key to success of nutrition care
plan
 ostomates can receive conflicting instructions
without collaboration
 important in monitoring effectiveness of
antidiarrheals
 coordinate management of nutrition issues to
improve consistency and effectiveness of care

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REFERENCES & RESOURCES

1. Wischmeyer PE, Carli F, Evans DC, et al. American society for enhanced recovery and perioperative quality initiative joint
consensus statement on nutrition screening and therapy within a surgical enhanced recovery pathway. Anesth
Analg.2018;126:1883-95.
2. Carmichael JC, Keller Ds, Baldini G, et al. Clinical practice guidelines for enhanced recovery and rectal surgery from the
American Society of Colon and Rectal Surgeons and Society of American Gastrointestinal and Endoscopic Surgeons. Dis Colon
Rectum. 2017;60:761-784.
3. Buckman SA and Heise CP. Nutrition considerations surrounding restorative proctocolectcomy. Nutr Clin Pract. 2010;25:250-
256.
4. Van der Aa F, De Ridder D, Van Poppel H. When the bowel becomes the bladder: changes in metabolism after urinary
diversion. Pract Gastroent. 2012;107:15-28.
5. DiBaise JK, Parrish CR. Short bowel syndrome in adults- Part 1, physiological alterations and clinical consequences. Pract
Gastroent. 2014;132:30-39.
6. Chan LN, DiBaise JK, Parrish CR. Short bowel syndrome in adults- Part 4A: A guide to front line drugs used in the treatment of
short bowel syndrome. Pract Gastroent. 2015:139:28-42.
7. Dowhan L, Moccia L, Corrigan ML, Steiger E. The clinician’s pocket guide to the nutritional management of intestinal
rehabilitation and transplantation for adults and pediatrics. Cleveland Clinic. 2020

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