15. Management of Patient with Ileostomy - Prevention and Management of Complications

In this class, we're going to continue our discussion of Iliostomy management, but our focus will be on prevention and management of complications. We'll talk about common complications associated with Iliostomy and discuss specific measures to prevent dehydration, to prevent food blockage, B12 deficiency, and renal calculi development. And we'll talk about management of these complications as well. So let's just go back and review what's going on when we have a patient with Iliostomy, because that explains why they are at risk for these complications. So we have either removed or bypassed the colon. The colon's primary job is to pull water and electrolytes out of the stool, to convert liquid stool to solid stool. And as such, you can see that the colon plays a major role every day in prevention of dehydration. But now that colon has been bypassed or removed, it is up to the small bowel to pick up the slack to absorb sufficient water and electrolytes from the stool to prevent dehydration. This is a particular challenge during the early post-operative period following Iliostomy formation. And actually, as you see from that second bullet point, dehydration is the most common reason for hospital readmission among patients who require Iliostomy. Quick review, usual volume of output for a patient with Iliostomy ranges from 500 milliliters to 1,100 milliliters. Compare that to the amount of water lost from an intact colon. So the amount of water typically lost through the colon every day is 100 to 200 milliliters. So you're losing significantly more every day if you have Iliostomy. And that means that individuals with Iliostomy need to increase their daily intake of fluid to at least 2,500 to 3,000 milliliters. So average adult needs 2 liters, average adult with Iliostomy needs 2.5 to 3 liters of fluid intake every day to prevent dehydration. So here's our general guidelines that we reinforce over and over when we're talking to an individual with Iliostomy. First of all, every day you've got to get in your baseline level of 2 liters a day. So let's talk about how much you typically drink at breakfast during the morning, at lunch, during the afternoon, at dinner, and between dinner and bedtime. Are you getting in your baseline 2 liters a day or do we need to increase your base level of fluid intake? And then remember that every time you empty your pouch, you're typically emptying about 8 ounces, so you want to get in the habit of every time you empty your pouch, wash your hands, go to the kitchen, get a glass of fluid. It could be a glass of water. It could be a glass of juice. It could be a glass of tea, a cup of coffee. Water is the best or an electrolyte beverage, like one of the electrolyte replacement beverages you can get in a natural food store in any kind of sports venue where they sell a lot of oral rehydration solutions. Or if you're going to buy something over the counter, you can look at Power 8-0 or G2. You want the water, you want the electrolytes, you really don't want the sugar. The sugar is an osmotic agent that pulls more fluid into the gut and actually increases output through the oleostomy. So 2 liters every day baseline and extra glass of fluid every time you empty your pouch. And again, there are some good choices. Pediatrics, they use a lot of pdolite or rehydrilite, but you know what, a lot of adults prefer those as well because they have limited flavor, they're not strong. So you can offer pdolite, rehydrilite to adults as well as children. And then anytime you're engaged in activities that cause increased fluid loss, what if at summertime and you're hiking, what if you're playing tennis, what if you're going to the gym and working out, you need to increase your fluid intake to compensate. And for increased losses through perspiration. Anytime your volume of output through your ostomy increases, you've got to increase your fluid intake. So one reason I really like teaching patients to replace fluids every time they empty their pouch is then they automatically compensate when their volume of output increases. If I empty my pouch four times a day, I'm drinking four extra glasses of fluid if I empty my pouch. Six times a day, I'm taking in six glasses of additional replacement fluid. So it's a really good rule of to teach your patients. You also want patients to be very tuned in to early signs of dehydration. You don't want them to get to the point where they need to go to the emergency room before they know they're in trouble. So what are some early signs of dehydration? Well you know these, a dull headache, feeling really tired, dry mouth, dark urine, mild nausea, possibly some muscle cramps. As soon as they notice any of these things, you want them to increase their fluid intake. So we try to teach our Ileosomy patients, pay attention every time you go to the bathroom to urinate, pay attention. What color is your urine? Is that very light, good? You're where you need to be. Is it getting dark? You've got to increase your fluid intake. Same thing. You've got a dull headache before you pop, add, veil, or Tylenol. Think about your fluid intake. Think a couple of glasses of fluid and see how you feel in 30 minutes. Now sometimes patients will get into a situation where they cannot replace. Maybe they have a GI bug, so they're having increased output through their ostomy. But they're also very nauseated and they just can't drink. Or maybe they're actively vomiting. So everything they take in results in increased fluid loss. So if they're unable to replace fluids, they have to go to the emergency room. They can get dangerously dehydrated. They can develop dangerous levels of hypochalemia and end up in cardiac arrest. So they cannot play around with this. You have to teach them. Dehydration is very serious, dehydration can kill you. So you've got to maintain fluid intake on a daily basis. You have to be very alert to early signs of dehydration and respond. If you're unable to meet your fluid needs, you have to go to the emergency room. Now let's talk about Iliostomy patients who have high volume output. And first of all, what do we mean when we say high volume output? Typically the cut off is considered to be 1,200 milliliters a day. So most surgeons use that when they're evaluating Iliostomy output and this individual's risk for dehydration, their need for IV fluids. Is your output greater than 1,200 milliliters a day? As your output increases, your risk of dehydration increases as well. What are the basic things you can do if your output is increasing? If you typically enter your pouch four times a day, but it's one o'clock in the afternoon and you've already emptied five times. Okay, in addition to increasing your fluid intake, you want to change what you're eating and you want to eat things that slow peristasis and thicken the stool. So you want to go on a low residue diet. You want to avoid vegetables. You want to avoid anything like trail mix, anything with peels, anything nuts, anything like that. Anything that can stimulate peristasis. Think about the brat diet, bananas or green plantains, green plantains are growing. rice, apple sauce, tea, toast, those kinds of things. Also, soluble fiber can be very helpful, very beneficial in thickening the stool. So they could try metamusel or some other psyllium product, two teaspoons and four ounces of water. Three to four times a day, we use that a lot for our Iliostomy patients. So we get them in the habit of taking psyllium and three to four ounces of water just before each meal, to see if that will help to slow the gut thick in the stool. Banana flakes, same thing. And some people do better with banana flakes. Some people do better with psyllium so you can try both. Also, antimotility agents can be tremendously helpful and bringing output down to a manageable, normal level. So the two big anti-diarrheal agents that are used are diphenoxylate and low paramide. Occasionally, we'll use tincture of opium, but not nearly as often and usually on a short-term basis. How much can they take? They can take the upper end of normal dosing. So with diphenoxylate, the maximum dosing is considered to be five milligrams, three to four times a day. Low paramide, of course, the great thing about low paramide is available over the counter. You can get chewable or rapidly dissolving forms which are tremendously helpful because otherwise, they may take the anti-diarrheal and it might pop right out into their pouch. So encourage them, get the chewable, get the form that rapidly dissolves. And they can take up to 16 milligrams a day. So that's eight tablets. So we want to do everything we can to slow the gut, looking at what they're eating, looking at psyllium or banana flakes and looking at anti-motility agents. We want to provide IV fluids as needed for dehydration prevention. Now it's easy to do that when they're in the hospital, but what about when they're at home? So if we have a patient with persistent, high volume output, we have to arrange for them to be followed by home health. We have to make sure that home health has orders to provide IV fluids under these circumstances. If output is higher than this, then they should get a replacement bag of IV fluids. And then, from just a management perspective, very helpful to encourage them to use a high output pouch when they're having episodes of diarrhea so that they can effectively monitor and so that they're not having to empty as frequently. So dehydration, one very important potential complication, the most common complication for individuals with ileostomy, the most common reason for readmission. So we want to pay a lot of attention to volume of output, to fluid replacement on a daily basis. We want to make sure our patients recognize these signs of dehydration and know how to respond. Okay, another potential complication is food blockage. We mentioned this very briefly in a previous class. So let's talk about why this is an issue for a patient with an ileostomy, but really not for a patient with a colostomy. And it all goes back to the diameter of the ileum. So the ileum is typically one inch in diameter, which is a fairly narrow passage, fairly narrow limit. It can be even narrower at fashion level where they turn the bowel to bring it through the abdominal wall. So maybe instead of being an inch, it's three quarters of an inch. And early post-operative is even narrower because the bowel wall is swollen. So during the early post-op period, the first six to eight weeks, maybe you're looming at the fashion level is a half an inch. And that's very narrow. So then you think, okay, well, what is this person eating? And are they taking in significant amounts of insoluble fiber? Because the issue with insoluble fiber is not broken down by enzymes. So instead of turning into mush, insoluble fiber is still a plug of collagen and other materials that are not broken down. And you can get a plug forming right proximal to the fashion level, to the fashion muscle layer. And then that creates a blockage. So if you have a bolus of undigested, high soluble or undigested insoluble fiber sitting just proximal to the fashion muscle layer, then everything backs up beyond that point, proximal to that point. And you get bowel distinction, you get cramping pain, you get nausea, you may get vomiting, and you're getting very little or no output. So we want to prevent that. Not because it's going to be fatal, but because it's going to be miserable. And we don't want people to go through miserable things. So we want to explain to them the diameter of the small bowel is typically one inch. And right now it's less because of swelling. There are foods that do not break down. And if you eat very much of that type of food, you can get a plug that causes a blockage. We don't want that to happen. Here's what we want you to do. We want you to avoid high fiber foods, foods high in insoluble fiber, until all the swelling goes down. Once all the swelling goes down, we want you to add those foods one at a time in small amounts so we want you to get in the habit of chewing really well. Because when you chew really well, you take that insoluble fiber and you break it down into much smaller bits. That can pass through much more readily. So you can have either a partial food blockage or a complete blockage. We're gonna talk about each one and how they would present clinically and what we would tell the patient. So if partial blockage is just what it sounds like, you do have a bolus of insoluble fiber, but it's not completely blocking the lumen of the bowel. It's further narrowing the lumen of the bowel. So now maybe we're down to a quarter to a third of an inch pathway. So instead of having a four-lane highway, everything's having to get by in the emergency lane. What would be the symptoms? Well, think about what's gonna happen. Things aren't gonna pass through readily. So you're gonna have some degree of stasis proximal to this blockage. And when you have any degree of stasis, you start to get bacterial overgrowth. Bacterial overgrowth causes breakdown of the insoluble fiber. Starts to break down the insoluble fiber to some extent, but also causes a lot of odor, the bacterial overgrowth. So now you have this malodorous, then watery drainage that's scooting past. So the output looks different, smells worse. So they'll be like, I don't know. It doesn't smell right. It doesn't look right. Yes, I'm having stuff come out in my pouch, but it's really watery and it smells really bad. And my belly swelling and I'm cramping. It seems to me my stoma is swollen. It looks bigger than usual. And I just don't have any appetite on borderline nauseous. Occasionally they'll have vomiting, but not typically. So the most common presentation is watery, foul smelling output, cramping pain, abdominal distinction, anorexia, maybe a little bit of mouth nausea, but usually no vomiting. Okay, well here we just want to weight it out and we want to prevent dehydration. So we tell them don't eat any solids. Wait till everything goes back to normal before you eat any solids, but continue fluid intake 'cause you've got to prevent dehydration. So yes, please keep drinking enough fluid, maintain your two liters, that is your baseline intake. And in additional glass every time you empty the pouch. If your stoma looks swollen, we want you to take off your existing pouch. Cut a new pouch with a larger of two liters. opening to accommodate the swollen stoma. You don't want any compression of the stoma. So change out your pouch. Very helpful to take a warm bath to relax the muscles and increase the lumen slightly. And the other thing they can do is peristoma massage, where they're pushing in, inferior to the stoma. It's kind of like the homelike maneuver for an iliostomy. So what you're trying to do is you're trying to create increased pressure in the proximal bowel and kind of pop some of that bolus through the opening. Get it out. Some people say it helps them to get in a knee chest position. It's easier for them to do the massage and to facilitate evacuation of that bolus of high fiber food. Most of the time, people who have a partial blockage, it gradually resolves on its own. And so if they can just keep their fluid and take up, prevent dehydration of voice solid food, typically within 8 to 12 hours it resolves. A complete blockage is where the entire lumen of the bowel is blocked. So now you have such a big plug of insoluble fiber that nothing can get around it. Nothing can get through. So it's like having a tractor trailer jackknife across the entire interstate. So what happens? Everything rapidly backs up proximal to the blockage. So you get rapid development of abdominal distinction. You have intense cramping pain because the body's trying to force things through. Yes, you almost always have stomola demon. You have pretty early development of nausea and vomiting. So these people are miserable. They're in pain. They're distended. They're nauseous. They're vomiting. It's awful. This is what we want to prevent. We don't want this to happen to our patients. So if they call, let's say you have an outpatient who calls in, tells you what's going on. You're like, I'm pretty sure you have a food blockage. Here's what I want you to do. I want you to avoid any intake. I don't want you drinking fluids. I don't want you eating. I want you to change out your pouch and large the openings so you're not causing any constriction of the stoma. I want you to take a warm bath and try massaging around the stoma to see if you can break any of that loose. And then if nothing happens and you're no better, you've done those things. It's going to take you about 45 minutes. I want you to go to the emergency room. And what they'll do in the emergency room, they'll usually do an X-ray or a CT to verify, yes, there's an apparent blockage just proximal to the stoma. And they will give them pain meds, they'll give them medication for nausea, they'll start IV fluids to prevent dehydration. And then they'll do a lavage to eliminate the blockage, which we'll talk about in just a minute. I want you to point out that when they do the X-ray or the CT scan, that will also help to rule out a blockage due to adhesions. So what if they find that, oh yes, there is definitely a blockage, but it's at midpoint in the ilium. And it appears to be due to adhesive bands. Then it's not a food blockage at all. It's a small bowel obstruction from adhesions. And yes, they still need IV fluids. They still need pain medication. They still need nausea medication. But now they probably need nasal gastric tube placement to decompress the proximal bowel, and they may require surgical intervention. So getting that X-ray or that CT is very helpful in distinguishing between a food blockage and a small bowel obstruction due to adhesions. OK, so now let's talk about iliolavage. Iliolavage can be done by an ostomy nurse. It can be done by a surgeon, anybody who's been taught how to do this. And what we want to do is pass a catheter to the level of the food blockage and then gradually break up the blockage by irrigations with saline. So first we do a general digital exam to see can I feel the blockage? Because it's usually just past fashion level. So a lot of times I can feel it. Sometimes I can break it up a little bit with my finger. If so, I'm going to do anything I can to break it up. Then I'm going to take a red rubber catheter, typically 16 to 18 French, lubricate the end, pass it and until I reach the blockage. And then I'm going to take a catheter tip syringe, fill it with 30 to 50 milliliters of warmed saline. So the whole time I'm doing my exam and getting the patient set up, I'm warming my saline. Now one thing I didn't mention that I should have mentioned is it's extremely helpful to put on an irrigation sleeve before you do this, because otherwise, you're going to be in a mess. So take off the pouch, put on the irrigation sleeve, do your digital exam, feed the red rubber catheter into the level of the blockage, then take your syringe of saline, attach it to the red rubber catheter, force that saline in fairly rapidly, because you want to break up this mess. So you want a little bit of force to break up the mess. Then remove the catheter to permit returns. Then put the catheter back, another syringe of warmed saline, push it in, take the catheter out, see what comes back. And when you do this, you're so happy. When you start to break up this mess, when you start to see things come out, that makes you really happy. I remember one patient I had, and she had eaten a pizza with mushrooms, and she hated mushrooms, but she didn't want to tell her date, that she hated mushrooms, so she tried to just swallow them without chewing them much, so she wouldn't taste them very much. And when we started seeing mushrooms come out, she and I were both so happy. So it makes you feel really good when you start seeing some of this high fiber mass come through the ostomy into your irrigant, and then once you've broken the mess up enough that it can pass through, then you have free flow of intestinal contents. So you keep doing the irrigation until you have free flow of intestinal contents. And it can take, and the textbooks, they always say one to two hours, I found that typically it's less than an hour. And during that time, when you're talking to the patient about what happened, it gives you an opportunity to reinforce foods that can cause a blockage and guidelines for prevention. So remember anytime you're eating a new food that might contribute to a blockage, start with small amounts, chew really well, this is definitely a teachable moment. The third thing we wanna talk about, we've talked about dehydration prevention, we've talked about prevention and management of food blockage, the third thing we wanna talk about is medication modifications. So again, remember the colon is missing, and so any medication we give has to be absorbed completely in the small bowel. Now fortunately, most medications are absorbed either in the stomach or in the small bowel, but there are a few forms of medication that may not be completely absorbed, and you just have to be aware of this and alert to this possible issue. It's more likely to be an issue in a patient with high volume output, patient with any degree of short bowel syndrome. So across the board for a patient with an aliastomy, no laxatives, they already have liquid to mushy stool. They don't need a laxative and a laxative could cause dehydration. So we tell patients do not take laxatives. In general, people with an aliastomy need to avoid time release medications. They need to avoid ontaric coated medications in very large tablets because they may get in complete absorption. And again, much more of an issue for patients who have high volume output, any degree of short bowel syndrome, I have seen medications come out totally unchanged through the ostomy and people who have any degree have volume output. So you want to tell patients, okay, we want to make sure your medications work for you. We want to make sure you have a complete absorption. So in general, you're going to do better with liquid medication, chewable medication, medications that are designed to dissolve rapidly, small playing pills. If you have problems, it's going to be with time-released coated medications in large tablets. So you want them to notify any physician they go to, notify their pharmacists so they can provide them with appropriate forms of their medications. Also, you tell them pay attention. Anytime you start a new medication, pay attention. Make sure that you're not seeing that medication come out into your pouch. I had one lady and if we gave her two pain pills, one would always come out in her pouch, like her ostomy was regulating her pain medication. One's enough, but that's a take-home message, pay attention to what you see when you empty the pouch. You want to be aware if medications are being incompletely absorbed. So you can let the physician know and you can get a change. And the type of medication. Now the last few things we're going to talk about may or may not be an issue for any particular patient. B12 deficiency. So as we discussed in previous classes, intrinsic B12 complex is absorbed only in the terminal elium, the last 100 centimeters of the small bowel. Now most people with an eliosdomy, that's not an issue because they don't really lose much at all of their terminal elium, maybe 10 to 20 centimeters. So for most patients with an eliosdomy, this is not a concern. But what if you have a patient who has Crohn's disease and had a small bowel resection for Crohn's disease and an eliosdomy. And when you go back and you review the surgical report, you find that they remove 60 centimeters of the terminal elium. Now they have less than half of the absorptive surface for vitamin B12 intrinsic factor complex. So that patient is definitely at risk for B12 deficiency. So any patient who loses a significant portion of the terminal elium is at risk for B12 deficiency, especially if they also have any degree of active inflammation compromising normal absorption. So Crohn's disease patients who lose significant portions of the terminal elium are at risk. One of the difficult things is that B12 is stored in the liver for up to three years. So there's a variable lag time between surgical resection of the terminal elium and own set of symptoms of deficiency. So we have to educate patients who have undergone partial resection of the terminal elium. Look, we took out a portion of the bowel that absorbs B12. That means that down the road you're at risk for developing B12 deficiency. And that can cause some significant problems. It can cause anemia, so that you're wiped out all the time. But more significantly it can damage the nerves in your feet and your fingers. It can cause numbness and tingling and that might not be reversible. So here's what you need to do. You need to communicate with your physician. You need to get your B12 levels checked at least twice a year. Four times a year would be even better. And as soon as your B12 levels start to drop, you need to go on B12 replacement for the rest of your life. We can easily prevent problems related to B12 deficiency, but we've got to monitor your levels and we've got to provide replacement. So what are the symptoms of B12 deficiency? We've already said anemia, so they feel very fatigued. They're intolerant of activity. They may be cold a lot. They can also develop irreversible neuropathy. That's what we were just mentioning. Over time, B12 deficiency can contribute to cognitive impairment and to depression. So we definitely want to prevent that. And we've already talked about how? It's pretty straightforward. Monitor levels. If levels start to drop, they either need injectable B12 or sublingual B12. Sublingual B12 is available over the counter. Very easy to take. But again, they should have their levels monitored to be sure that they're getting adequate replacement. And then we wanted to briefly mention renal calculine kidney stones. So why would somebody with aneliostomy be at increased risk for kidney stones? Well, the primary reason is because they're borderline dehydrated all the time. Their urine is much more concentrated. So that in and of itself places them at risk for kidney stone formation. In addition, they lose a lot of bicarb through the ileostomy. As a result, they have more acidic urine. So the body compensates for the loss of bicarb by excreting more hydrogen in the urine and trying to hang on to bicarb. So the urine becomes more acidic and that increases their risk for uric acid stones. Furthermore, they tend to be at risk for calcium oxalate stones because they have more calcium and more oxalate in their urine because of metabolic changes. So three reasons, they're at increased risk. Their borderline dehydration unless they're doing a phenomenal job of increasing their fluid intake. Their urine tends to be more acidic due to bicarb losses. The acidity and the urine is risk factor for uric acid stones. They also tend to excrete more calcium and more oxalate in the urine because of metabolic changes and that places them at risk for calcium oxalate stones. The number one preventive measure is maintain high volume fluid intake. If you can maintain high volume fluid intake, you keep all of these minerals in solution and you don't end up with stones. If they develop a stone, it should be analyzed so they know what kind of stone they have and then they can take further preventive measures. If they have a uric acid stone, there's measures that can be taken to keep the urine more alkaline and to prevent precipitation of uric acid. If they have calcium, oxalate stones, it can be helpful to acidify the urine. So we need to know what we're dealing with in any patient who does develop a stone. But ideally, we'll prevent stones by maintaining high volume fluid intake. So in managing a patient with an aliastomy, we have to realize that bypassing or removing the colon does create changes that place them at increased risk for dehydration. The fact that the lumen of the small bowel is one inch max places them at risk for food blockage. The fact that the colon's been bypassed places them at risk for incomplete absorption of medications. Individuals who have undergone significant resection of the terminal ilium could develop B12 deficiency and any patient with an aliastomy can develop kidney stones because of dehydration and metabolic changes. So when we're managing these patients, our education, our counseling, has to include preventive measures for all of those complications. Thank you very much.