RICHARD JOHNSTON 06/09/13 High output stoma

Case of: High output ileostomy Jejunostomy

Baseline Recently 39 yrs old lady 6yr history of recurrent stricturing CD Right hemi 5yr ago no cigs BO 3*/day 5-ASA B12 nil else Obstructive episodes 2 * 5-10cm distal SB strictures Weight loss of 7kg from 66kg BMI 23 No oedema Elective Small Bowel resection

Findings Procedure extensive distal small bowel disease with a walled off perforation around the neo- terminal ileum Adhesions++ abscess and distal small bowel was fully removed en masse with no drains inserted Primary anastomosis was not made colon remained in situ end ileostomy formed. remaining small bowel was assessed to be healthy and ~ 3.5 m in length. Laparotomy

Clinical assessment Stoma volume3 litres/day sepsis/obstructionNo clinical evidence 24 hours urinary volume 800 ml iv fluidsnil Oedemanil Eating little Drinking2.5 litres of squash/water/tea renal biochemistrynormal Day 5 post-op

Clinical assessment Stoma volume3 litres/day sepsis/obstructionNo clinical evidence 24 hours urinary volume 800 ml iv fluidsnil Oedemanil Eating little Drinking2.5 litres of squash/water/tea renal biochemistrynormal Day 5 post-op What to do?

Early high output Ileostomy >2l/day Present in 20% of ileostomies Normally no cause found, and resolves in >50% Mortality ~ 8% (sepsis) Aetiology: Obstructed Sepsis – intra-abdominal Enteric disease: Inflammation/infection - C Diff Medication Short bowel: Jejunostomy Nightingale et al. Colorectal Disease 2009

Losses depend where it comes from NICE 2013 Page 40 of 189

Losses depend where it comes from NICE 2013 Page 40 of 189

Small bowel stoma + electrolytes Under-replaced salt and water losses Rising urea and creatinine Low sodium – serum or urine Secondary hyperaldosteronism: low magnesium and potassium Low Potassium = dehydrated (assuming > 50cm jejunum) NOT phosphate – if low then pt refeeding

Plasma, ileal fluid and iv fluid contents Type of fluidSodium (mmol/l) Potassium (mmol/l) Chloride (mmol/l) Osmolality Plasma136–1453.5–5.098–105280–300 Ileal losses ~280 5% Dextrose Dex/saline ‘Normal’ saline Gelofusine Ringer’s lactate Hartmann’s

Plasma, ileal fluid and iv fluid contents Type of fluidSodium (mmol/l) Potassium (mmol/l) Chloride (mmol/l) Osmolality Plasma136–1453.5–5.098–105280–300 Ileal losses ~280 5% Dextrose Dex/saline ‘Normal’ saline Gelofusine Ringer’s lactate Hartmann’s

Dangers of sodium and fluid XS Our ancestors faced dehydration Nature has developed many strategies to overcome sodium and water deficiency No methods to excrete XS sodium or water So no defence mechanism to abnormal saline

Clinical Lab Fluid balance charts Weights Oedema 30ml/hr Urinary sodium <20mmol/L: secretor/ retainer Plasma urea and creatinine (catabolic state, low protein intake and reduced muscle mass) Sodium low Magnesium and potassium low Fluid and electrolyte balance

Oral hypertonic fluids Can avoid iv fluids in ¾ patients and nutrition support in 2/ ml hypotonic fluids/day Nightingale et al. 2009

Hypertonic fluids

Supportive medical management for a high output stoma Start PPI – gastric hypersecretion, no change in macronutrient absorption Loperamide (?syrup) – enterohepatic circulation Codeine Octreotide – reduces high output stoma losses but no benefit on energy/nitrogen balance and may induce fat malabsorption. Expensive and painful NB: Loperamide and codeine CI in obstruction Stop NSAIDs, laxatives, prokinetics Screen C diff

Case continued... Urinary Na 7 mmol/L 2L Hartmann’s Daily fluids: 500 ml oral hypotonic fluids 1 litre hypertonic glucose–saline increase oral food intake loperamide 8mg qds omeprazole 40 mg bd Stomal losses 1-1.5L/day Mobile

What can she eat with her new ilesostomy? What she likes vs. Low residue

Day 9 Fevers, vomiting and RIF tenderness CT – collection and obstruction Laparotomy – adhesions and internal fistulae Surgical drain and stoma re-fashioned at 140cm HDU Iv antibiotics

Issues? Solutions ? What are the

Issues Solutions Sepsis PEM 140cm SB What are the

Issues Solutions Sepsis PEM 140cm SB Antibiotics and drain EN / PN..... What are the

Intestinal failure ‘inability to maintain protein-energy, fluid, electrolyte or micronutrient balance from either obstruction, dysmotility, surgical resection, congenital defect or disease associated loss of absorption’. Sub classified into three types: Type 1 Self-limiting. E.g. ileus, IF is temporary and often predictable support fluid, electrolytes +/- nutrition with PN Type 2 Intestinal failure in severely ill patients Major bowel resection or a septic patient with metabolic or nutritional complications. Most overcome their initial acute illness with only a few develop type 3 IF Type 3 Chronic intestinal failure requiring long term nutritional support Chronic intestinal failure even after resolution of the acute illness and intestinal adaptation.

Long-term requirements by jejunal length Jejunal length (cm) Jejunum–colonJejunostomy 0-50PNPN + electrolytes ENPN + electrolytes NilEN + OGS NilOGS

S N A P E D Sepsis Nutritional status – energy, protein, electrolytes Anatomy Plan Edema (fluid balance) Drugs Assessment

Open abdomen with jejunal fistulation

S sepsis may not be classical, can get C diff in SB Low threshold for CT Culture lines

S sepsis in this pt We have a cunning plan of antibiotics and drain

Macronutrient Micronutrient MUST Recent intakes Weight loss signs Anthropometry Current dry weight urea and creatinine Albumin Low K, Phos, Mg predict refeeding risk No role for a ‘full nutrient profile’ N nutritional status clinical assessment

The case... Day 10 post admission with little orally during admission and pre-ceding PEM Handgrip - weak No oedema but further 2kg wt loss Low urea and creat Normal K, Mg and PO4 Albumin

Albumin in healthy volunteers after 2l fluid in 1hr Clin Sci Lobo et al.

Very low albumin often looks like...

Jejuno-colon Jejunostomy Adaptation via peptide YY No adaptation A anatomy

Long-term requirements by jejunal length Jejunal length (cm) Jejunum–colonJejunostomy 0-50PNPN + PE ENPN + PE NilEN + OGS NilOGS

Prognosis Possible outcomes Anatomy Underlying condition Complications Co-morbidities Potential further surgery ( days) Home PN TLC P plan

HPN service here in Torbay 15pts ? A new full PN pt soon 6/52 MDT combined clinics Homecare service

Edema

Fluid balance and initial recovery after elective colonic resection Lobo et al Lancet 2002

Median passage of flatus was 1 day earlier (3 vs. 4 days, p=0·001); median passage of stool 2·5 days earlier (4 vs. 6.5 days, p=0·001); Fluid balance and initial recovery after elective colonic resection

PPI (po vs. iv) St Marks Anti-motility D Drugs to consider starting

Anti-motility + obstruction Pro-motility Loperamide/codeine Opiates Baclofen Metoclopramide Laxatives Others: NSAIDs D Drugs to consider stopping

What should we encourage jejunostomy pts to eat?

High energy requirements – can be double habitual May need overnight NG +/- PEG Ideally low fat to aid absorption but this means a greater food volume (tolerance) and can become EFA deficient Normally recommend energy-dense foods with a high salt content: normally high fat and low residue. Little amounts and often - snacks+++ Fluids taken with a meal may increase losses Loperamide 30 min pre food

The management of this pt with 140cm jejunostomy PPI, loperamide and codeine. Hypertonic fluids Little and often plus sip feeds PN as a bridge for about a week Elective re-anastamosis 6 months later Off all treatments bar questran Weight stable, but BO ~5-6*/day

In conclusion Early high output ileostomy – watch and wait then gentle anti-motility. Assess for sepsis, obstruction, untreated luminal disease / infection, drugs Intestinal failure SNAPED Integrated care from GI surgeons, physicians, radiologists, stoma team, dietitians, nutrition nurses, pharmacists etc. Be wary of fluid XS

Nutrition state assessment?

MUST

Standard ONS IE – AA and n-3 PUFA Pre-op ONS in GI surgery pts, Cochrane 2012