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Management of a High Output Stoma, Jejunotomy or Uncomplicated Enterocutaneous Fistula

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Intestinal Failure

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Abstract

A high output stoma (HOS) or fistula is when the output (almost always from the small bowel) causes a patient to become water, sodium and often magnesium depleted. This tends to occur when the output is more than 2 L/24 h though this varies according to the amount of food/drink taken orally (if 4 L are consumed a 2 L output may not be a problem but if only 0.5 L is taken and the output is 2 L then dehydration will follow). A HOS occurs in up to 31% of small bowel stomas. It rarely occurs if there is more than half of the colon in continuity with the small intestine. It may occur in a fistula if it is situated in the proximal small bowel or if there is a degree of bowel obstruction or ischaemia.

The management starts with excluding causes other than a short bowel and treating them (especially partial or intermittent small bowel obstruction, or ischaemia). It is helpful to have an approximate measurement of the length of remaining functioning small bowel in circuit (preferably from surgery but if not available from a radiological assessment).

If HOS is due to a short bowel the first step is to rehydrate the patient so stopping severe thirst and the tendency for them to drink hypotonic fluid. Then oral hypotonic fluid is restricted and a glucose-saline solution sipped. Medication to slow transit (loperamide often in high dose) or reduce secretions (omeprazole for gastric acid and rarely octreotide for both gastric and pancreatico-biliary secretions) may be helpful. Magnesium depletion is common and may be treated with magnesium oxide, aspartate or glycerophosphate capsules, correction of dehydration, and 1α-hydroxycholecalciferol. Subcutaneous fluid (usually saline with added magnesium) may be given before parenteral fluids. 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. GLP-2 (or in future PYY) agonists may provide a means of increasing absorption.

Recurrent admissions with HOS can result in chronic renal failure, so the occurrence of a chronic HOS needs to be detected early and carefully monitored. Ideally there should be a specialist local service (often a hospital Nutrition Support Team) following these patients.

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    Jeremy M. D. Nightingale

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Nightingale, J.M.D. (2023). Management of a High Output Stoma, Jejunotomy or Uncomplicated Enterocutaneous Fistula. In: Nightingale, J.M. (eds) Intestinal Failure. Springer, Cham. https://doi.org/10.1007/978-3-031-22265-8_39

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