Makindo Medical Notes

💧 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)

🧲 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

🎯 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

🧪 St Mark’s Solution (Home ORS)

• 🧃 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