• Reference Number: HEY1470-2024
• Departments: Dietetics
• Last Updated: 30 August 2024

Introduction

This leaflet has been produced to give you general information about your condition. Most of your questions should be answered by this leaflet. It is not intended to replace the discussion between you and your doctor, but may act as a starting point for discussion. If after reading it you have any concerns or require further explanation, please discuss this with a member of the healthcare team caring for you.

What is a high stoma/fistula output?

If a stoma output is over 1 litre a day this is classified as a high output.  A fistula output of over 500ml per day is also classified as a high output.

What causes a high output stoma/fistula?

High stoma/fistula output can be a short-term problem following surgery and may resolve quickly.

If a stoma/fistula output is high for a longer length of time, tests may be carried out to check for potential absorption problems, which may be treatable.

Alternatively, if a stoma/fistula is formed high in the bowel then there is not an adequate length to allow the body time to reabsorb nutrients and fluid and this may be the cause of the high output.  This may improve over time as the gut adapts.

Can there by any complications or risks?

High output stomas/fistulae can lead to weight loss and low vitamin and mineral levels due to reduced absorption across the gut wall. High amounts of fluid losses from your stoma can also lead to dehydration and problems with salt levels in the body.

What is the treatment for a high output stoma/fistula?

The treatment is dependent on the cause of the problem but may include:

• Treatment of an absorptive problem if tests find a cause.
• Dietary changes.
• Oral fluid restriction.
• Medicines to help slow down stoma output.
• Fluids or nutrition via a drip if dehydration or malabsorption if concern.

Dietary changes

If you have a high output stoma or fistula you should be referred to the dietitian to discuss diet.

A diet reduced in fibre may be recommended.  Foods to be avoided include brown bread, wholegrain pasta, brown rice, salad vegetables, fruits and vegetables with skins, wheat biscuits, bran cereals, beans and pulses as they are high in fibre.

High fat foods may also need to be restricted if these appear to be causing a problem.

If a reduced fibre or fat diet is likely to be required longer term, a multivitamin tablet may be recommended to ensure vitamin and mineral needs are met.

If your appetite is reduced, you may find it easier to eat small amounts more frequently.  Try to focus on foods which are high in calories and protein which your dietitian will advise on.

If weight cannot be maintained with diet alone, your dietitian may recommend nutritional supplements or feeding via a feeding tube or centrally placed venous catheter. 

Oral Fluid Restriction

If your stoma is high in output, you may be advised to follow a fluid restriction for normal (hypotonic) fluids (tea, coffee, milk, squashes, water) to help slow losses, your medical team will advise on this. These fluids are all low in sodium and draw sodium and fluid into the bowel, causing an increase in stoma/fistula output and salt losses.

In addition to a fluid restriction for hypotonic fluids you may be started on an electrolyte mix – these fluids are better absorbed in the bowel as they contain higher amounts of salts and as a result will help reduce losses from the stoma.  The solutions currently used at Hull University Teaching Hospitals are Dioralyte at a double strength concentration (10 sachets in 1 litre of water) and St Marks Solution (you may be asked to make up this medication, a recipe will be supplied by your specialist if this is required).

If you are finding your fluid restriction difficult or have questions, speak with your dietitian or stoma nurse for advice. 

Commonly Used Medicines

• Antimotility medicines

Work by slowing the movement of the bowel and as a result increase absorption of nutrients and fluid.

• Loperamide: Can be taken in doses up to 16 milligrams (mg) (eight tablets or melts) four times a day. These work best if taken 30 minutes before food.
• Codeine: Can be taken in doses up to 60 milligrams (mg) four times a day.

• Antisecretory medicines

Work by reducing the amount of secretions produced and a result reduce fluid losses.

• Proton Pump Inhibitors eg. Lansoprazole and Omeprazole– these medicines work by reducing acid production in the stomach, this can help reduce losses and help protect the skin. They are normally taken once to twice per day.
• Octreotide/Lanreotide – these are injections which are given into the muscle which are sometimes trialled to reduce losses. They can be painful therefore if these injections have little effect when trialled they are stopped.

• Electrolyte/Vitamin and Mineral Corrections

You may also require medicines to supplement magnesium losses and vitamin and mineral intake.  This will be guided by blood tests and monitored regularly, your specialist will advise on the frequency of these tests.

A daily multivitamin and mineral supplement is recommended to help maintain levels.

Weight loss

If you are unable to maintain your weight you should gain advice from a dietitian on ways to increase your oral intake if possible.  This may entail:

• Fortifying foods to increase the calories and protein content of your meals for example: adding double cream, cheese or butter/margarine.
• Changing meal pattern to a small and often approach with introduction of snacks between meals.
• Drinking nourishing fluids such as milk, milkshakes or supplement drinks.

If these measures are not successful, feeding via a tube or line may be required.

Recognising dehydration

Symptoms of dehydration may include:

• Dry, sticky mouth
• Increased thirst
• Light headedness or feeling dizzy
• Tiredness
• Headache
•  Passing less urine
•  Muscle cramps

The colour of your urine is a good guide to see how well hydrated you are. A clear, pale yellow colour suggests good hydration, whereas a dark yellow colour may indicate you are getting dehydrated.

If dehydration is an issue and cannot be managed with the steps outlined above intravenous fluid may be used to improve hydration.  Avoid drinking more fluids as this will increase bowel losses and further dehydrate you.  Consider taking additional electrolyte mix (Dioralyte/St Marks) and inform the nutrition team or stoma nurses if no improvement.

Ongoing monitoring

On discharge you will receive a sheet for weight monitoring and fluid balance tables to keep a record of your progress.

Should you require further advice on the issues contained in this leaflet, please do not hesitate to contact the Dietetic Department tel: 01482 674490 or Stoma Nurse Team on tel: 01482 624026