💧 High-Output Stoma - use this pathway when stoma output is typically >1.5 L/24 h (or >1.0 L/24 h with dehydration/electrolyte issues) or fistula output >500 mL/24 h (Type 2/3 intestinal failure).
🎯 Goal: keep the patient hydrated, safe, and comfortable while you reduce output.

🧾 Introduction

🔍 Common causes: infection/bacterial overgrowth, obstruction, recurrent IBD, medication effects (pro-kinetics, sudden steroid/opiate withdrawal), short bowel.
👩‍⚕️ Specialist input is essential. Even after correcting triggers, many patients need ongoing support to prevent dehydration/malnutrition.
📏 Applies to stoma output ≥1000 mL/day (or fistula ≥500 mL/day) and intestinal failure types 2–3.

🧪 Step 1a - Assessment

🧴 Fluid balance chart daily; target urine >800 mL/24 h (≈>0.5 mL/kg/h).
🥗 Discuss diet early (see Dietary Management below).
🧫 Check U&Es/minerals (Na⁺, K⁺, Mg²⁺, PO₄³⁻, Ca²⁺); correct IV if needed; recheck daily while adjusting therapy.
🧪 If hyponatraemic, check urinary sodium (normal >20 mmol/L).
💊 Deprescribe contributors (pro-kinetics, sorbitol-containing liquids, recent steroid/opiate changes).
📞 Escalate early: inform on-call surgery; involve stoma nurses and dietitians.

🚰 Step 1b - Rehydration & Stabilisation (trial therapies)

✅ Intervention	💊 Typical regimen	💡 Why / Tips
🚫 Hypotonic drinks	Limit to ~500 mL/24 h initially	Plain water/tea increase output; swap to ORS sips.
💧 IV fluids/electrolytes	Meet remaining needs IV	Restores intravascular volume without driving intestinal losses.
🥤 ORS (double-strength Dioralyte)	1 L/day (1 sachet/100 mL)	Uses Na⁺-glucose co-transport; note ~40 mmol K⁺ per litre.
🛑 Loperamide	2–4 mg PO QDS 30–60 min pre-meals & bedtime	Prefer tablets/open capsules; avoid sorbitol liquids; review after 2–3 days.
🧯 PPI (lansoprazole)	30 mg PO OD (IV/dispersible if <50 cm small bowel)	Reduces secretions; watch for low Mg²⁺.
💤 Codeine phosphate	30–60 mg PO QDS 30 min pre-food	Anti-motility; sedation/constipation & dependence → frequent review.

🧲 Low Magnesium (PPIs can worsen)

💊 Magnaspartate® 10 mmol sachets dissolved in 50–200 mL water/tea/juice.
🌙 Start 1 sachet nocte; titrate to max 3/day (≥3/day off-label). Monitor for diarrhoea.
💉 Give IV Mg as needed in secondary care to maintain levels.

🛌 Step 2 - Consider Gut Rest

⏳ Trial NBM for 24 h with full IV replacement.
🔬 Helps distinguish fluid-driven vs net-secretory output.

🥤 Step 3 - Fluid Optimisation

🧂 Start St Mark’s Solution 1 L/day sipped over 24 h + 1 L allowed hypotonic fluid (adjust totals ~50:50 to match needs).
⏲️ Reassess after 2–3 days.

💊 Step 4 - Medicines Optimisation

💊 Medicine	📈 Dosing strategy	⚠️ Key cautions
Loperamide (specialist high-dose)	Up-titrate by 2–4 mg PO QDS every 2–3 days to max 24 mg QDS	Off-label at high doses; consider ECG if very high totals (rare QT risk with misuse).
Codeine phosphate	60 mg QDS (≤30 mg QDS if eGFR <20 mL/min)	Sedation/falls, dependence; taper to avoid rebound ↑ output.
Octreotide (SPECIALIST)	50–200 micrograms SC TDS	Often short-lived (tolerance); monitor glucose & gallbladder.
Comfort measures	Artificial saliva sprays PRN	👍 Eases thirst/dry mouth when oral fluids are limited.

🎯 Goals of Treatment

💧 Maintain fluid balance and adequate urine output.
🧪 Correct electrolyte disturbances (especially Na⁺, Mg²⁺).
⚖️ Stabilise weight/nutritional status.
📉 Reduce stoma volume to a manageable level.

🍽️ Dietary Management

✅ Do	🚫 Avoid	🥤 Fluids	📝 Notes
High-energy, high-protein meals. Low-fibre starch at each meal (potatoes without skins, white rice/pasta/bread; low-fibre cereals like cornflakes). 🍎 Snack between meals.	High-fibre foods (wholegrains, pulses, skins/stalks/seeds, nuts, porridge); spicy/fried/fatty foods; leafy greens; sugar-free products with sorbitol/xylitol/mannitol.	Sip slowly through the day. ⏳ Avoid drinking with meals - leave ~30 min before/after. Make ORS the main drink.	If persistent hyponatraemia: 🧂 add salt to food and include salty snacks. Thicken output with low-fibre carbs, gelatin-containing foods (marshmallows/jelly), eggs, cheese, milk puddings, and 🍌 one banana/day.

🧪 St Mark’s Solution (Home ORS)

🧁 Glucose powder	6 level teaspoons (~20 g)
🧂 Sodium chloride (table salt)	1 level teaspoon
🥄 Sodium bicarbonate	½ teaspoon
🚰 Water	1 litre (tap or bottled)

🧃 Mix well and chill. You may add a little cordial/squash for taste - do not dilute further with water.
🥤 Sip across the day; aim for ORS as your main oral fluid.

🧠 Teaching Points (friendly explainer)

🔗 ORS works because glucose drags sodium (and water) across the gut wall even when surface area is reduced; plain water can worsen losses.
🕒 Loperamide + PPI pair transit slowing with secretion reduction - a simple, effective first-line combo.
🧪 Urinary sodium is a quick check for under-replacement of sodium in high-output states.

📚 References

High-output stoma guideline

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High Output Stoma