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High Ostomy Output

I. Background

High ostomy output (>1 liter/day) can result in dehydration, malnutrition, and prolonged hospitalization. A standardized approach improves outcomes and reduces length of stay.

II. Guideline

A. Patient on Oral Diet or Bolus Tube Feeds

  1. Applies regardless of remaining bowel length
  2. Discontinue all oral bowel regimens
  3. Avoid high-sugar and sugar alcohol drinks
    • Examples: electrolyte sports drinks, sweet tea, colas
  4. Ensure strict I/Os are documented (all PO/enteral intake)
  5. Switch to carbohydrate-restricted diet
  6. Convert liquid medications to tablet/capsule form if possible
  7. Order IV fluid replacement
    • 1:1 IVF q4h PRN for UOP < 0.5 mL/kg/hr or signs of dehydration
  8. Assess for parenteral nutrition (PN) if:
    • High output >1 week
    • Protein-calorie malnutrition confirmed by dietitian

Output Thresholds:

  • Colostomy >700 mL/day
  • Ileostomy >1000 mL/day

Stepwise Management:

Step Medications
1 Metamucil BID (stop if decreased appetite) + Loperamide 2 mg AC/HS
2 Loperamide 4 mg AC/HS + Pantoprazole 40 mg IV BID
3 Diphenoxylate/Atropine 5 mg AC/HS
4 Diphenoxylate/Atropine 10 mg AC/HS
5 Tincture of Opium 0.5 mL AC/HS
  • Reassess output after 48 hours; advance to next step if not improved
  • Dietitian should re-evaluate diet with each escalation

B. Patient on Continuous Tube Feeds

  1. Applies regardless of remaining bowel length
  2. Discontinue all bowel regimens
  3. Use a standard polymeric formula (e.g. Replete, Isosource, Nutren)
    • Consider bolus feeding if patient can tolerate
  4. Convert liquid meds to tablet/capsule form
  5. Replace fluids as needed
    • 1:1 IVF q4h PRN for UOP < 0.5 mL/kg/hr or dehydration symptoms
  6. Consider PN if:
    • High output >1 week
    • Malnutrition confirmed by dietitian

Output Thresholds:

  • Colostomy >700 mL/day
  • Ileostomy >1000 mL/day

Stepwise Management:

Step Medications
1 Loperamide 2 mg q6h
2 Loperamide 4 mg q6h + Pantoprazole 40 mg IV BID
3 Diphenoxylate/Atropine 5 mg q6h
4 Diphenoxylate/Atropine 10 mg q6h
5 Tincture of Opium 0.5 mL q6h
  • Reassess output after 48 hours; advance to next step if needed
  • Dietitian should re-evaluate formula/diet during escalation
  • If maximum therapy fails after 48 hours, discuss escalation with attending

III. References

  1. Parrish CR, Copland A. Enteral Nutrition in the Adult Short Bowel Patient. Pract Gastroenterol. 2021: 36–51.
  2. Kumpf VJ. Pharmacologic Management of Diarrhea in Patients with Short Bowel Syndrome. JPEN. 2014;38(Suppl 1):38S–44S.
  3. Bridges M, et al. High Output Ileostomies: The Stakes Are Higher Than the Output. Pract Gastroenterol. 2019: 20–33.

IV. Authors

  • Joshua P. Smith, DO
  • Jennifer Beavers, PharmD
  • Leanne Atchison, PharmD
  • Diana Mulherin, PharmD

Date: January 22, 2024