Ostomy Care

Question 1

Indications for ostomy

Answer 1

• Cancer - Colon & Rectal Cancers (most common)
• Diverticulitis
• Perforated bowel
• Bowel obstruction
• Crohn’s disease
• Ulcerative colitis
• Birth defects/Congenital Conditions
• Accidental injury/Trauma

Question 2

What is an Ostomy?

Answer 2

An ostomy is an artificial opening of the body, created by surgery
* In the case of most ostomies, this refers to the connection of a portion of bowel to the outside of the body (also called a stoma) for the purpose of waste excretion

Question 3

What are the most common types of ostomies?

Answer 3

• ileostomy
• colostomy
• Urostomy or Ileal Conduit

Question 4

Ileostomy

Answer 4

connection of the small bowel to the exterior of the body
* To remove or bypass the entire colon and rectum, or to protect a distal colorectal, coloanal, or ileoanal anastomosis
* Can be constructed either as a diverting loop stoma or end stoma, with or without a continent reservoir

Question 5

colostomy

Answer 5

connection of the large bowel to the exterior of the body
* To bypass or remove the distal colon, rectum, or anus and it is either inadvisable or not feasible to restore gastrointestinal continuity
* If the sphincter mechanisms are removed, the colostomy is permanent
* As with ileostomies, colostomies may be created in a loop or end fashion

Question 6

Urostomy or Ileal Conduit

Answer 6

diversion of urine to the exterior of the body

Question 7

What are small bowel surgeries?

Answer 7

• Small bowel repair
• Small bowel resection: duodenectomy, jejunectomy, ileectomy
• Lysis of adhesion: adhesiolysis

Question 8

what are colon surgeries?

Answer 8

• right hemicolectomy: part of or all right side (ascending) colon is removed. The remaining colon is then reconnected to the SI
• left hemicolectomy: part of or all left side (descending) colon is removed. The remaining colon is then reconnected to the rectum
• sigmoid colectomy: part or all of the sigmoid colon is removed. the descending colon is then reattached to the rectum

Question 9

What are rectal surgeries?

Answer 9

• low anterior resection: The sigmoid colon and a portion of the rectum are removed, descending colon is reattached to the remaining rectum
• abdominal perineal resection: part or all of the sigmoid colon and the entire rectum and anus are removed. A colostomy is then performed

Question 10

Types of stomas

Answer 10

• end stoma
• loop stoma
• double barrel stoma

Question 11

Intestinal Sites of Nutrient Absorption

Answer 11

• Ileum: absorption of vitamin B12 and bile acids
• Colon: absorption of water and electrolytes (sodium, potassium)

Question 12

Postoperative nutrition

Answer 12

Question 13

What is reccomended in a low fibre diet?

Answer 13

• Choose lower fibre foods
• Avoid higher fibre foods

Question 14

Soluble vs. insoluble fibre

Answer 14

Soluble Fibre
* Water soluble
* Thickens stool → good for high output ostomies
* Safe for new ostomies

Insoluble Fibre
* Water insoluble / stays in same form
* Bulks stool
* Increases risk of obstruction

Question 15

Long term nutrition with ostomy

Answer 15

• After 6-8 weeks most people can return to “normal” intake (a regular fibre diet, no restrictions)
• Some people will find that some foods are more difficult for them to tolerate / may cause symptoms like gas/odor, bloating, looser output, etc.
• still important to achieve adequate fluid intake to prevent dehydration
• Bowel adaptation may or may not occur, and often takes several months

Question 16

How does food tolerations change with ostomy?

Answer 16

• They may or may not have the same food intolerances as before their ostomy
• Encourage food journaling to determine what exact foods, amounts and types of preparation methods are triggering
• It is common for people to continue to avoid very high insoluble fibre foods for risk or concern of obstruction

Question 17

Indications for micronutrient supplementation with ileostomy

Answer 17

• Vitamin B12 supplementation is indicated if > 60 cm of the ileum is resected
• Fat soluble vitamin supplementation is indicated if > 100 cm of the ileum is resected and steatorrhea occurs

Question 18

Indications for micronutrient supplementation with colostomy

Answer 18

No specific recommendations if functioning well

Question 19

Indications for micronutrient supplementation with hight output ostomy

Answer 19

Electrolyte replacement, Magnesium, Zinc & Selenium due to large losses

Question 20

Micronutrient reccomendation for all ostomy patients

Answer 20

Can be helpful for all ostomy patients to take a chewable or liquid multivitamin daily at minimum during the healing period, or longer based on their overall nutrition status and intake
* NEVER recommend gummy multivitamins

Question 21

Managing gas, bloating and smell

Answer 21

All these things are normal and okay
* There are no specific foods that cause gas/bloating and/or odor for everyone; these things are highly individualized
* Recommending people avoid foods initially can be harmful by needlessly limiting their options
* Try food journaling if noticing increased gas/bloating or smell with certain foods before eliminating any

Question 22

What things do impact gas, bloating and smell?

Answer 22

• Eating quickly
• Chewing gum
• Drinking with a straw or from a bottle
• Carbonated beverages

Question 23

How is ostomy output determined?

Answer 23

The type and volume of output is determined by the location of the stoma relative to the ileocecal valve

Question 24

Output with ileostomy & ascending colostomy

Answer 24

• Output is more liquid consistency due to reduced water absorption
• Ostomy requires emptying several times per day
• Output contains some degree of digestive enzymes that can be irritating to the skin/mucosa

Question 25

Output with descending & sigmoid colostomy

Answer 25

* Output is more formed (stool) * Output amount varies → may empty ostomy bag several times or not at all in a day * Output does not contain digestive enzymes

Question 26

Expected ostomy output over 24 hrs for ileostomy

Answer 26

1200 mL (mature 600-800 mL) * contains significant amounts of Na and K * Increased risk of dehydration, especially during episodes of increased output

Question 27

Expected ostomy output over 24 hrs for colostomy

Answer 27

200-600 mL * Can go a day or so without any output (constipation possible)

Question 28

What is high output defined as?

Answer 28

>1000-1500 mL * most common in ileostomies, shortly after surgery (~1200 mL expected) * can become a complication if persists long term

Question 29

What contributes to loose outputs?

Answer 29

* Spicy foods: least amount of evidence to support * Caffeine: reduces intestinal transit time + diuretic effect * Very high fat foods: when missing part of the ileum, increased risk of steatorrhea * Very high sugar foods: draws water into the bowel * Alcohol: can have laxative effect + diuretic effects * Sugar alcohols: draws water into the bowel

Question 30

Signs of dehydration

Answer 30

* dry mouth * dry skin * headaches * thirst * dizziness * muscle cramping * nausea * low blood pressure * low or dark urine output

Question 31

What is critically high ostomy output?

Answer 31

>2000 mL daily * Require hospitalization for IV hydration until output improves or a long- term outpatient IV therapy plan can be established

Question 32

What populations are at risk for high ostomy output?

Answer 32

* Extensive surgical resection (< 200 cm residual bowel, short bowel syndrome) * More proximal location of the stoma (higher in the GI tract, ex ileostomy) * Intra-abdominal sepsis or infection enteritis * Partial or intermittent bowel obstruction * Recurrent disease in the remaining bowel (ex Crohn’s) * Sudden discontinuation of medications (ex steroids, opioids → constipating) * Use of prokinetic medications (ex metoclopramide → stimulate gut movement) * Bacterial overgrowth or enteric pathogens

Question 33

Nutrition for high output ostomy

Answer 33

Question 34

Fibre for high ostomy output

Answer 34

* Soluble fiber can thicken output → it does not decrease stool volume or enhance absorption * Dietary sources: oatmeal, barley, lentils, psyllium (Metamucil), applesauce, smooth peanut butter, fruits and vegetables with the skin/peel removed * Fiber bulking agents may be effective. Can often make patients feel full = difficulty meeting nutritional needs

Question 35

Oral rehydration solutions

Answer 35

Oral rehydration solutions are Isotonic * Promote absorption of water by being similar in solute concentration to the bowel * Fluid with modest amounts of sugar and salts (Na, K) to promote hydration * Does not decrease stool volume

Question 36

What do hypertonic fluids do?

Answer 36

pull water into small bowel to dilute higher osmolarity fluids = increasing stool volume * Milk, popsicles, fruit juice, soda, broth, ONS

Question 37

What do hypotonic fluids do?

Answer 37

fluids pull sodium into the small bowel to increase osmolarity of the fluid = increasing stool volume * Na never travels alone, always brings water along * Water, tea, coffee, sugar free drinks

Question 38

Recipes for oral rehydration solutions

Answer 38

Limit regular fluids to < 500 mL daily Sports drinks are NOT isotonic + need adjustments to be considered ORS * Regular Gatorade is hypertonic: 1 1⁄2 cups Gatorade + 2 1⁄2 cups water + 1⁄2 tsp salt * G2 is hypotonic: 4 cups G2 + 1⁄2 tsp salt Juice recipe example * 3⁄4 cup 100% juice + 3 1⁄4 cup water + 1⁄2 - 3⁄4 tsp salt Soup recipe example * 4 cups water + 1 dry bouillon cube + 1⁄4 tsp salt + 2 tbsp sugar

Question 39

Drugs?

Answer 39

* **Anti-diarrheals**: loperamide, Lomotil, codeine * **Fibre supplements** (Metamucil): not effective without a colon * **Cholestyramine**: for bile acid induced high output ostomy (following terminal ileum resection) * **Anti-secretory**: pantoprazole, omeprazole, ranitidine, octreotide (somatostatin)

Question 40

What should be monitored daily in thr hospital for hydration status?

Answer 40

Monitor electrolytes (Na, Cl, K), Mg, Phos, Creatinine, Urea daily * Avoid enteral electrolyte replacement to prevent worsening outputs

Question 41

When is PN used?

Answer 41

* Preferred method if unable to achieve adequate PO intake * Often require increased fluid and electrolyte provision (Na, Cl, K, etc.) due to increased losses

Question 42

When is EN used?

Answer 42

* Okay to use polymeric and fibre containing formulas * Osmolarity can be an issue * Formulas are often hyperosmolar * Isotonic: Isosource Fibre 1.0 HP, Peptamen w/ Prebiotics * Close to isotonic: Isosource 1.0 HP, Peptamen Intense * In high output, may need ORS via tube → exchange water flushes for “ORS” flushes

Question 43

Nutrition with ostomy reversal

Answer 43

Following an ostomy reversal, there are no specific dietary restrictions * A patient’s bowel habits will be heavily impacted by the amount and health of bowel added back after the reversal * Patients who maintain limited colon length following an ostomy reversal may experience looser bowel movements and/or chronic diarrhea postop (reccommendations to follow high output ostomy diet)