Stoma care & high-output stoma 💧
On-call stoma care: leaking bag, dusky stoma, no output, and high-output ileostomy. Restrict hypotonic fluid, sip St Mark’s or double-strength Dioralyte, start loperamide, and protect the kidneys.
📞 Overnight calls
- Typical bleeps: leaking or overflowing bag, dusky or black stoma, no output, or high watery output with thirst, dizziness, or a rising creatinine.
- See the patient. Inspect the stoma and bag contents. Check for a postural BP fall >10 mmHg, oliguria (<800 mL/24 h), and a recent weight.
- Urostomy (ileal conduit) is urine, not stool. Do not use the high-output ileostomy pathway. Mucus in the bag can be normal.
🧠 Types and usual output
- Ileostomy: small bowel. Once established, about 600–1200 mL/24 h and porridge-like. More liquid early on. Loop ileostomies run high more often than end ileostomies.
- Jejunostomy: proximal small bowel, often <200 cm remaining. Output is often high and does not settle with time.
- Colostomy: colon. Usually formed or semi-formed and lower volume. High watery output with intact small bowel is uncommon. Think obstruction with overflow, infection, or ischaemic colitis.
- New stomas are swollen. Colour should still be pink or red and moist. Ileostomy adaptation takes weeks to months.
🚨 Red flags
- Dusky, purple, black, or dry stoma, especially in the first 72 hours: possible ischaemia. Call the surgical registrar now.
- Peritonism, fever, or new high output in the first 3 weeks: exclude intra-abdominal sepsis and ileus. Early high output is often sepsis-related.
- Colicky pain, loud bowel sounds, then a flood of output: partial obstruction recovering. Do not load antimotility drugs until obstruction is out.
- Shock, anuria, or climbing creatinine from stoma losses: hypovolaemia. IV 0.9% sodium chloride. Do not tell them to drink lots of water.
- Irreducible prolapse, tight parastomal hernia with vomiting, or heavy stomal bleeding: senior surgical review.
🔍 Look at the stoma
- Mucosa should be pink or red, moist, and slightly proud. Pale, dusky, black, flush, or retracted is not. A flush stoma leaks under the bag, especially with liquid output.
- Ileostomy effluent is alkaline and burns peristomal skin quickly if the bag leaks.
- Chart volume (millilitres, not just bag counts), colour, and consistency. Effluent Na is about 100 mmol/L. Yellow-green watery output in an established ileostomy can mean a short remaining small bowel.
- A gentle digital exam of the os can detect stenosis. Do not force or dilate. If you are not trained, ask surgical or the stoma CNS.
💧 High-output stoma
- HOS is output high enough to deplete water, sodium, and often magnesium. Usually >1.5–2 L/24 h (BAPEN often uses >2 L). A lower volume still counts if they drink little, have heart or kidney disease, or bags leak unmeasured.
- Early (within 3 weeks) in about 16% of small-bowel stomas; overall up to about 30%. Unusual if more than half the colon is in continuity.
- Exclude causes other than short bowel: intra-abdominal sepsis, ileus, C. difficile, partial obstruction (often at the stoma), metoclopramide, opioid or steroid withdrawal, metformin, laxatives, recurrent disease (e.g. Crohn’s), chemo or immunotherapy enteritis, coeliac disease, thyrotoxicosis, small-bowel diverticula, ischaemic segment, internal fistula.
- Read the operation note for remaining length, not length removed. <200 cm jejunum to a stoma is high risk. <100 cm often needs parenteral fluid.
🚑 Overnight HOS pathway
- Thirsty, hypotensive, oliguric, or creatinine up: IV 0.9% sodium chloride (often 2–4 L over the day, reassess). Little or no oral intake until thirst and renal function improve. Output is driven by what they drink.
- Never advise drinking as much as possible. Hypotonic fluid (water, tea, coffee, squash, juice, alcohol) pulls sodium into the lumen and raises output. Hypertonic drinks and elemental feeds do the same.
- Once oral: hypotonic drinks 500–1000 mL/24 h, plus 1 L of high-sodium ORS sipped through the day. If output is only about 1–1.5 L and they are well, extra dietary salt may be enough.
- St Mark’s (Na ~90 mmol/L, no K⁺): glucose 20 g, sodium chloride 3.5 g, sodium bicarbonate 2.5 g, water to 1 L. Pharmacy can make it. If potassium is high or they have AKI, use St Mark’s, not Dioralyte.
- Double-strength Dioralyte is 10 sachets in 1 L (not 5). Na ~120 mmol/L. It contains potassium (~40 mmol/L), so check K⁺ if renal function is reduced. Single-strength Dioralyte and sports drinks are too low in sodium (<90 mmol/L).
- Strict fluid balance, daily weight, drainable high-output bag. Stop metoclopramide, laxatives, and other prokinetics. Review metformin. Low-fibre diet if adhesions or intermittent obstruction are possible. Do not stop heart-failure diuretics without a senior if they are overloaded. Diuretics readily precipitate AKI with an ileostomy.
💊 Medicines to cut output
- Give antimotility drugs 30–60 minutes before meals and at bedtime. Output rises after food.
- Start loperamide 4 mg QDS if not already on it and obstruction is not suspected. Tablets are preferred: capsules may pass unused. Product licence max is 16 mg/day. High-dose HOS titration (BAPEN up to 16 mg QDS) is a senior or nutrition-team step, not an overnight jump.
- ECG (QT) before high-dose loperamide (more than 4 mg QDS) and again after starting. Do not add other QT-prolonging drugs without a senior. Keep the total daily dose below 80 mg.
- If output rises after antimotility drugs, think partial obstruction and stop them. Octreotide is rarely used: it is roughly equivalent to omeprazole in net secretors and is not an intern overnight start.
🧪 Electrolytes and tests
- Bloods: U&E, Mg²⁺, K⁺, Ca²⁺, phosphate, FBC, CRP. Magnesium depletion is common (especially jejunostomy) and can be almost asymptomatic.
- Random urine Na <20 mmol/L suggests sodium depletion (<10 is clearly significant). Aim >20 mmol/L. Unreliable on diuretics, IV saline, or recovering AKI. Serum Na can look normal until late.
- Correct sodium depletion first: that often improves magnesium. Oral magnesium (e.g. oxide) is first-line and need not increase output. IV if they cannot take oral or levels stay low. About a third of serum Mg is bound to albumin, so a low result with hypoalbuminaemia can be misleading. Correct K⁺ in parallel.
- Watery output and recent antibiotics: send C. difficile from the bag. Isolate if infective diarrhoea is likely.
- Do not start TPN overnight. Refer dietetics and nutrition or surgery in hours if output stays high or remaining bowel is short.
🩹 Leaking bag and skin
- Liquid output plus a flush stoma equals leaks. Repeated standard bag changes overnight will not fix it.
- Ask for a drainable high-output bag and a barrier ring or paste from the stoma cupboard. Stoma CNS in hours. Night coordinator if skin is already raw. Photograph raw skin if the patient agrees.
- Clean with water, dry, protect skin, then a bag cut to fit. Adhesive remover wipes are not a substitute for a better appliance.
🚫 No output
- Quiet ileostomy after recent surgery may be ileus. A colostomy that stops plus vomiting and distension is obstruction until proven otherwise.
- NBM, IV fluids, NG if vomiting, surgical review. No laxatives or metoclopramide into an obstruction.
- Painful parastomal hernia with no output: treat as hernia obstruction. Escalate.
📋 Handover
- Record stoma type, operation date, remaining small-bowel length if known, 24 h input and stoma output, urine output, U&E, magnesium, allowed oral fluid, which ORS, and the loperamide dose.
- Do not fill and send home without a hypotonic-restriction and ORS plan. One missed day and they bounce back.
- Refer stoma CNS and dietetics for the morning. Gastro or nutrition if this is recurrent or remaining bowel is short.
Note Template
Ready-to-use clinical note structure
🕒 16 / 10 / 2026 — 16:17 ATRP re: stoma / high-output stoma Patient: [age] [sex] Admission Dx: [reason for admission] PMHx: [IBD, cancer, mesenteric ischaemia, short bowel, heart failure, CKD] Operation: [date] [loop/end ileostomy / jejunostomy / colostomy / urostomy] Remaining small bowel: [unknown / __ cm] 🧾 Hx: • Call: [leaking bag / high output / no output / dusky stoma / AKI] • Output last 24 h: __ mL (or bags: __) — consistency [watery / porridge / formed] • Oral intake: [hypotonic drinks __ mL / ORS / NBM] • Thirst, cramps, dizziness, stool from bag overnight • Meds: [loperamide dose / codeine / PPI / metoclopramide / laxatives / diuretics / metformin] • Allergies: 🩺 Exam: • Vitals: HR __ BP __ (postural drop >10 mmHg Y/N) Temp __ • Oliguria (<800 mL/24 h): [Y/N] • Stoma: colour [pink-red / dusky / black] — height [proud / flush / retracted] • Peristomal skin: [intact / raw / leaking] • Abdomen: [soft / distended / peritonism / hernia] • Bag contents inspected: [yes] 🔬 Investigations: • U&E: Na __ K __ urea __ creat __ (baseline __) • Magnesium: __ Phosphate: __ • Urine Na: __ mmol/L (depletion if <20; aim >20; interpret off diuretics / IV saline) • C. difficile: [not sent / sent] • Blood gas / lactate if unwell 📋 Impression: [High-output ileostomy with dehydration / AKI / leaking appliance / possible ischaemia / obstruction / other] 📌 Plan (BAPEN BIFA 2023 / Nightingale 2022): • Ischaemia or peritonism: [not suspected / surgical registrar called] • Fluids: [IV 0.9% NaCl / oral restriction 500–1000 mL hypotonic + 1 L St Mark’s or double-strength Dioralyte] • Stop: [metoclopramide / laxatives / metformin reviewed] • Loperamide: [4 mg QDS tablets before meals; ECG before high-dose more than 4 mg QDS] • PPI / codeine: [not started / omeprazole 40 mg daily if net secretor / codeine with senior] • Magnesium: [correct Na first / oral Mg / IV if oral not possible] • Low-fibre diet if obstruction/adhesions possible: [Y/N] • Appliance: [high-output bag requested / stoma CNS] • Referrals: [stoma CNS / dietetics / nutrition or gastro in hours] • Do not discharge on IV fill alone without an oral fluid plan 👤 [Your Name], [Role] IMC: _______
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