ileostomy formation is occasionally required in patients with complicated inflammatory bowel disease requiring colonic resection .
this procedure can lead to a number of recognised complications including stomal obstruction , stomal prolapse , skin erythema and ileal inflammation .
a less commonly described complication is high output ileostomy which occurs when there is a disproportionate fluid and electrolyte loss through the stoma . in the first few days after ileostomy formation
, there is frequently an increased stool effluent through the stoma , but this rapidly decreases because of 
ileostomy adaptation . the normal output through an ileostomy following a total colectomy is between 400 and 600 g of stools daily .
in a high output ileostomy , stool output is more than 1,000 g daily , which can result in severe dehydration and electrolyte imbalance . while impaired
 ileostomy adaptation has been used to describe the pathogenesis of high output ileostomies , there is now an increasing body of evidence suggesting that enteral infection with clostridium difficile might contribute to the cause [ 3 , 4 ] .
while it is difficult to estimate the incidence of this complication , it is certainly an important issue which has a significant effect on patients quality of life and significant morbidity and mortality . therefore adequate management of high output ileostomies is important . in this article
we present a patient with a high output ileostomy and describe the physiological changes that are believed to occur and the recommended management issues of this important complication .
a 42-year - old female lawyer with a 4-year history of ulcerative proctitis presented to our hospital with a 2-week history of worsening shortness of breath at rest , which was worse on exertion .
she had failed medical therapy ( which consisted of mesalazine 3.2 g daily since diagnosis , mesalazine enemas , azathioprine at a dose of 2.5 mg / kg for the previous 4 years and infliximab at a dose of 5 mg / kg every 6 weeks for the previous 3 years ) , and 2 months before her current presentation she had undergone a panproctocolectomy with ileal pouch formation and ileoanal anastomosis .
she had also required regular steroids in view of clinically active disease ( raised partial mayo score for ulcerative colitis ) , blood tests as manifested by anaemia and raised inflammatory markers and endoscopically active disease .
multiple stool samples for culture , ova , cysts , parasites , c. difficile toxins and colonoscopic biopsies had ruled out co - existent superinfection .
the patient had persistently refused to undergo colectomy until recently . the patient had no other symptoms besides shortness of breath . on initial assessment
she was tachycardic with a heart rate of 130 beats per minute and tachypnoeic with a respiratory rate of 30 breaths per minute and an spo2 of 93% .
in view of her symptoms , recent surgery and the above findings an echocardiogram was performed , which revealed a hypocontractile right ventricle .
meanwhile her initial blood investigations revealed a hypochloraemic metabolic acidosis on a background of dehydration as indicated in table 1 . on more detailed questioning ,
she had lost 6 kg since her surgery and had an effluent through the stoma of more than 2 litres per day .
other possible causes of high output stomas such as intraabdominal sepsis , bowel obstruction and infective enteritis were ruled out through the appropriate tests .
she was managed with 1 litre 0.9% saline 12-hourly and oral fluids with diarolyte sachets ( 0.47 g sodium chloride per sachet ) and an isotonic energy drink ( 0.11 g sodium chloride per 240 ml of fluid ) .
the patient was not keen on having codeine or lomotil to slow down the output through the stoma .
thus , she was prescribed omeprazole 40 mg twice daily orally which resulted in a decrease in the effluent through the stoma . on starting this treatment
her condition improved rapidly and she was discharged from hospital 6 days later , by which time her blood tests had all normalized .
after 3 months the dose of omeprazole was gradually reduced and then stopped and the patient underwent closure of her stoma .
 ileostomy adaptation refers to the physiological process that occurs in the small intestine whereby faecal output through a stoma decreases in volume and becomes less fluid .
this tends to occur within one to two weeks after ileostomy formation , but may take up to two years .
ileostomy adaptation requires cell hyperplasia and increased mucosal surface area with an increase in bowel circumference , an increase in length and bowel wall thickness , and an increase in villus height and crypt depth .
proctocolectomy and the establishment of an ileostomy leads to increased fluid and electrolyte losses even when adaptation is complete , and such patients are susceptible to salt and electrolyte depletion [ 2 , 5 ] .
a possible complication of this disproportionate increased output of water and electrolytes is a high output ileostomy .
serum gastrin is raised in patients who have undergone bowel resection [ 7 , 8 ] .
hypergastrinaemia has been shown to cause diarrhoea , possibly due to hyperacidity in the stomach .
in fact , patients with gastrinomas tend to present with diarrhoea as their initial complaint in up to 90% of cases . in the management of high output ileostomies with marked electrolyte and water depletion ,
replacing fluids by administering 24 litres / day of intravenous normal saline is of paramount importance .
keeping the patient starved initially is also important since the net output is driven by the oral intake .
treatment for high output from a stoma begins with the patient restricting the total amount of both oral hypotonic and hypertonic fluids to less than 500 ml per day .
the addition of a glucose - saline replacement solution ( 90 mmol / l sodium or more ) is required to make up the total fluid intake .
loperamide and codeine phosphate reduce intestinal motility and thus decrease water and sodium output from an ileostomy by approximately 2030% .
loperamide is preferred over codeine phosphate as it is not sedative or addictive and does not cause fat malabsorption . if tablets or capsules are seen unchanged in stool or stomal output , they can be crushed , opened , mixed with water , or put on food .
drugs that reduce gastric acid secretion ( for example , the h2 antagonists or proton pump inhibitors or the somatostatin analogue octreotide ) are also commonly used .
ranitidine ( 300 mg orally twice daily ) and omeprazole ( 40 mg orally daily or intravenously twice daily ) reduce stomal output , particularly in those with a net secretory output and generally in those with an output exceeding 2 litres every day .
omeprazole is readily absorbed in the duodenum and upper small bowel but if less than 50 cm of jejunum remains , it may need to be given intravenously .
these drugs , which inhibit gastric acid secretion , are as effective as octreotide ( 50 mg subcutaneously twice daily ) in reducing the volume of stomal output , but they do not change the absorption of electrolytes and do not reduce stomal output enough to reduce the severity of intestinal failure .
the greatest reductions in intestinal output are in those with a net secretory output , and the volume of parenteral supplements needed may be reduced .
the reduction in sodium output parallels that of intestinal output while magnesium balance is unchanged .
total energy and nitrogen absorption are not significantly changed while fat absorption may be unchanged or reduced .
long - acting octreotide or somatostatin preparations have not been assessed in large studies but may prove to be effective in the future .
mineralocorticoids or high - dose hydrocortisone may reduce stomal output in patients with a retained ileum .
some authors recommend that the management algorithm of a high output ileostomy should include exclusion of small bowel c. difficile , particularly in inflammatory bowel disease patients with a history of previous infection .
if clostridium toxins are found , treatment with oral metronidazole or vancomycin may result in quick resolution of symptoms .
we present a case of high output stoma following bowel resection which was managed by adequate rehydration and proton pump inhibitors .
this case highlights the importance of closely following and advising this group of patients with such stomas in order to prevent and identify as early as possible such complications .
 high output ileostomies are important complications of stoma formation following bowel surgery . 
 adequate management of such stomas might prevent severe morbidity and mortality when this potentially fatal complication develops . in this case report 
 , we describe a female patient with a recent ileostomy formation following panproctocolectomy for ulcerative colitis who presented with progressively increasing shortness of breath . 
 the patient was found to have a hypochloraemic metabolic acidosis on arterial blood gases . 
 she rapidly improved with adequate sodium and fluid replacement and with the use of a course of proton pump inhibitors . 
 this case highlights the importance of recognising high output ileostomies early and important management issues in their regard . 
Introduction
Case Report
Discussion