Nutritional management of a malnourished cancer patient with high output ileostomy

A case Report

  • Adelina Haryono Faculty of Medicine Universitas Indonesia – dr. Cipto Mangunkusumo General Hospital. Jakarta, Indonesia
  • Diana Sunardi Faculty of Medicine, Universitas Indonesia – dr. Cipto Mangunkusumo General Hospital
  • Wina Sinaga Faculty of Medicine, Universitas Indonesia – dr. Cipto Mangunkusumo General Hospital
Keywords: high output stoma, malnutrition, ileostomy, cancer

Abstract

High output stoma is a complication that may follow ileostomy formation, with an incidence of 23%. There is no general consensus on the limit of ileostomy production to be defined as high output. However, output of more than 2000 mL/day, can cause fluid and electrolyte imbalance, also malnutrition due to reduced nutrient absorption. Delay in recognition and treatment, especially in cancer patient with high risk of malnutrition, can further deteriorate patient’s nutritional status. A 43-year-old malnourished female with ascending colon cancer underwent tumor resection and ileocolostomy surgery. Starting from the third postoperative day, ileostomy effluent drastically increased to 2700 mL/day, causing severe hyponatremia, hypokalemia, and hypomagnesemia. Risk factors of high output stoma identified were routine prokinetic medication use and unresolved malignancy-related retroperitoneal abscess. Moreover, increment of food intake in the first days after surgery, specifically food high in insoluble fiber, was one of the contributing factors. High output stoma was then resolved by abscess drainage, discontinuation of prokinetic agent, and administration of antimotility agent. Hyponatremia and hypomagnesemia improved with correction, whereas hypokalemia needed longer time to resolve. Enteral nutrition was maintained and increased gradually to prevent further malnutrition. Oral hypotonic fluid intake was limited to 1000 mL/day and isotonic solution consumption was advised. High stoma production due to hypersecretory phase after ileostomy was expected, but thorough management would prevent patient’s deterioration that was caused by the fluid, electrolyte, and nutritional imbalances.

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Author Biographies

Adelina Haryono, Faculty of Medicine Universitas Indonesia – dr. Cipto Mangunkusumo General Hospital. Jakarta, Indonesia
Department of Nutrition
Diana Sunardi, Faculty of Medicine, Universitas Indonesia – dr. Cipto Mangunkusumo General Hospital
Department of Nutrition
Wina Sinaga, Faculty of Medicine, Universitas Indonesia – dr. Cipto Mangunkusumo General Hospital
Department of Nutrition

References

Hara Y, Miura T, Sakamoto Y, Morohashi H, Nagase H, Hakamada K. Organ/space infection is a common cause of high output stoma and outlet obstruction in diverting ileostomy. BMC Surg. 2020;20:83–90.

Bai D, Li L, Shen Z, Huang T, Wang Q, Wang Y, et al. Risk factors for developing high output ileostomy in CRC patients: a retrospective study. BMC Surg. 2021;21:300–6.

Uribe AA, Weaver TE, Echeverria-Villalobos M, Periel L, Shi H, Fiorda-Diaz J, et al. Perioperative Morbidity and Complications in Patients With an Established Ileostomy Undergoing Major Abdominal Surgery: A Retrospective Study. Front Surg. 2021;8:757269.

Pande RK, Gupta A. Gastrointestinal stomas and fistulas: What is lost and what to do. Indian Journal of Critical Care Medicine. 2020;24:S175-8.

Eustache J, Hopkins B, Trepanier M, Kaneva P, Fiore JF, Fried GM, et al. High incidence of potentially preventable emergency department visits after major elective colorectal surgery. Surg Endosc. 2022;36:2653–60.

Song HN, Wang W bin, Luo X, Huang DD, Ruan XJ, Xing CG, et al. Effect of GLIM-defined malnutrition on postoperative clinical outcomes in patients with colorectal cancer. Jpn J Clin Oncol. 2022;52:466–74.

Baker ML, Williams RN, Nightingale JMD. Causes and management of a high-output stoma. Colorectal Dis. 2011;13:191–7.

Adaba F, Vaizey CJ, Warusavitarne J. Management of intestinal failure: the high-output enterostomy and enterocutaneous fistula. Clin Colon Rectal Surg. 2017;30:215–22.

Bossi P, Delrio P, Mascheroni A, Zanetti M. The spectrum of malnutrition/cachexia/sarcopenia in oncology according to different cancer types and settings: A narrative review. Nutrients. 2021;13:1980.

Marshall KM, Loeliger J, Nolte L, Kelaart A, Kiss NK. Prevalence of malnutrition and impact on clinical outcomes in cancer services: A comparison of two time points. Clinical Nutrition. 2019;38:644–51.

Lee DU, Fan GH, Hastie DJ, Addonizio EA, Suh J, Prakasam VN, et al. The clinical impact of malnutrition on the postoperative outcomes of patients undergoing colorectal resection surgery for colon or rectal cancer: Propensity score matched analysis of 2011–2017 US hospitals. Surg Oncol. 2021;38:101587.

Takeda M, Takahashi H, Haraguchi N, Miyoshi N, Hata T. Factors predictive of high-output ileostomy: a retrospective single- center comparative study. Surg Today. 2019;49:482–7.

Mountford CG, Manas DM, Thompson NP. A practical approach to the management of high-output stoma. Frontline Gastroenterol. 2013;5:203–7.

Rowe KM, Schiller LR, Rowe KM, Schiller LR. Ileostomy diarrhea: pathophysiology and management. Baylor University Medical Center Proceedings. 2020;33:218–26.

Wu PE, Juurlink DN. Clinical Review: Loperamide Toxicity. Ann Emerg Med. 2017;70:245–52.

Dhingra D, Michael M, Rajput H. Dietary fibre in foods: a review. J Food Sci Technol. 2012;49:255–66.

Villafranca JJA, López-rodríguez C, Abilés J, Rivera R. Protocol for the detection and nutritional management of high-output stomas. Nutr J. 2015;14:1–7.

Nightingale JMD. The medical management of intestinal failure: methods to reduce the severity. Proceedings of the Nutrition Society. 2003;62:703–10.

Nakanishi R, Konishi T, Nakaya E, Zaitsu Y, Mukai T, Yamaguchi T, et al. Predisposing factors and clinical impact of high-output syndrome after sphincter-preserving surgery with covering ileostomy for rectal cancer: a retrospective single-center cohort study. Int J Clin Oncol. 2021;26:118–25.

Medlin S. Nutritional and fluid requirements: high-output stomas. Gastrointestinal Nursing. 2012;10:42–9.

Muscaritoli M, Arends J, Bachmann P, Baracos V, Barthelemy N, Bertz H, et al. ESPEN practical guideline: clinical nutrition in cancer. Clinical Nutrition. 2021;40:2898–913.

Submitted

2023-02-24
Accepted
2023-05-05
Published
2023-08-31