High output ileostomy (Ileostomy diarrhea)

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					High output ileostomy
 (Ileostomy diarrhea)

      2002-12-16
      Ri 顏琮洲
                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
               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)
        Pathophysiology(2)

• Excessive gastric acid secretion
  - lowering the intraduodenal pH
  - inactivate pancreatic digestive enzymes
    stimulate peristalsis
        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
             Adaptation(1)
• Potential : ileum > 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
                 Adaptation(2)
• Luminal nutrition is essential for adaptation
    change, and begin as soon as possible
•   small frequent feeding
    enteral drip tube feeding
•   Potential stimulants of adaptive growth
    - growth hormone, glutamine, soluble fiber...
                 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
    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
    Nutritional management (2)
• Enteral nutrition :
   - low amount, continuous gastric infusion
   - elemental diet
   - contribute to adaptive growth of the
      small bowel
             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 adaptation
  growth hormone, glutamine, other hormones...
          Surgical treatment

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