High output ileostomy (Ileostomy diarrhea)

1
High output ileostomy(Ileostomy diarrhea)

• 2002-12-16
• Ri ???

2
Ileostomy

• Total colectomy and minimal resection of terminal
  ileum (i.e. 10cm)- ileostomy output
  400-600g/day
• Longer resection of terminal ileum-ileostomy
  output larger, usually 1000g/day

3
Pathophysiology(1)

• reduced small bowel surface area for absorption
  of nutrients with more transit of intestinal
  content
• loss of mucosa containing brush border hydrolases
  affected carbohydrate digestion
• - non-absorbed sugars
• - osmotic diarrhea, rarely severe metabolic
  acidosis (lactobacilli convert the carbohydrate
  to D-lactic acid)

4
Pathophysiology(2)

• Excessive gastric acid secretion
• - lowering the intraduodenal pH
• - inactivate pancreatic digestive enzymes
• stimulate peristalsis

5
Clinical manifestations

• Malabsorption and Diarrhea
• (correlate with length, location, quality of the
  residual bowel)
• Potential for dehydration, hyponatremia,
  hypokalemia and acidosis
• (inadequate reabsorb fluid and e-)
• Deficiencies of Fe, Na, Ca, Mg, Zn, Cu, Se, Vit
  B12, fat soluble Vits

6
(No Transcript)
7
Adaptation(1)

• Potential ileum gt jejunum
• Immediately after loss of bowel, continue for
  years
• Included
• - cell hyperplasia and increase mucosal
• surface area
• - increase in bowel circumference
• - length and bowel wall thickness
• - villus height, crypt depth

8
Adaptation(2)

• Luminal nutrition is essential for adaptation
  change, and begin as soon as possible
• small frequent feedingenteral drip tube feeding
• Potential stimulants of adaptive growth
• - growth hormone, glutamine, soluble fiber...

9
Treatment

• Goal of management
• Initial
• - promote and maintain growth
• - adaptation changes in the residual
• bowel
• Eventual
• - permit full enteral feeding
• Nutrition, medical, surgical and small bowel
  transplantation

10
Nutritional management (1)

• TPN is necessary in the early stages
• - cholestatic jaundice with danger of
• progression of hepatic cirrhosis
• - cyclical TPN may decrease the risk
• - neomycin or metronidazole may reduce
• harmful bacterial translocation across the
  gut

11
Nutritional management (2)

• Enteral nutrition
• - low amount, continuous gastric infusion
• - elemental diet
• - contribute to adaptive growth of the
• small bowel

12
Medical treatment

• H2 blocker reduce the possible gastric
  hypersecretion improve the diarrhea
• Loperamide hydrochloride slow transit time and
  reduce secretion, but with risk of bacteria
  overgrowth
• Trophic factors in adaptationgrowth hormone,
  glutamine, other hormones...

13
(No Transcript)
14
Surgical treatment

• Not employed within 6 12 months after
  resection, due to widely individual variation in
  the potential for intestinal adaptation

15
Conclusion
16
Thanks for your attention