An ileostomy is a surgical procedure that creates an opening in the abdomen, called a stoma, to allow stool to bypass a damaged or diseased colon or rectum. This opening allows waste to exit the body. Understanding the long-term dietary needs following an ileostomy is crucial for maintaining health, preventing complications, and improving overall quality of life.
Understanding Ileostomy Procedures
During an ileostomy, a portion of the small intestine (ileum) is brought through the abdominal wall to form a stoma. A pouch is then connected to the stoma to collect stool. There are several types of ileostomies:
- End Ileostomy: The end of the ileum is brought through the abdominal wall, and the remaining portion of the intestine is sewn shut.
- Loop Ileostomy: A loop of the ileum is brought through the abdominal wall and partially cut, creating two openings: one for stool and one for mucus.
- Continent Ileostomy (Kock pouch): An internal pouch is created from the ileum with a valve to prevent leakage, emptied using a catheter.
Ileostomies can be temporary, allowing the bowel to heal, or permanent, when the colon, rectum, or anus is removed or irreparably damaged.
Why an Ileostomy is Performed
An ileostomy becomes necessary when the colon or rectum cannot safely process waste due to:
- Inflammatory Bowel Disease (IBD)
- Colon or Rectal Cancer
- Bowel Blockage
- Familial Adenomatous Polyposis (FAP)
- Trauma or Injury
- Diverticulitis Complications
- Congenital Conditions
Potential Risks and Complications
All surgeries carry risks, including bleeding, infection, blood clots, and pneumonia. Specific risks associated with ileostomies include:
Read also: Post-Surgery Diet for Ileostomy
- Prolapse
- Retraction
- Bleeding
- Stenosis (narrowing of the stoma)
- Hernia
- Necrosis (tissue death)
- Skin irritation
- Leakage
- Separation of the stoma from the skin
- High stool output or diarrhea
- Blockage
- Adhesions (scar tissue formation)
- Dehydration
- Problems absorbing nutrients
Adjusting to life with an ileostomy can also present psychological challenges, affecting mental health and overall quality of life.
Pre-operative Preparation
Proper preparation is essential for a smooth transition, whether the ileostomy is temporary or permanent:
- Preoperative Assessment: Evaluation of caffeine, alcohol, tobacco, and e-cigarette use, along with a review of all medications and supplements.
- Physical Strength: Engaging in light exercise, if approved by the healthcare team.
- Stoma Site Marking: Selection of an appropriate stoma site by a healthcare professional, considering skin folds, muscles, and scars.
- Diet and Fasting: Following a special diet or bowel-cleansing solution as instructed.
What to Expect During Ileostomy Surgery
Ileostomy surgery can be performed using open or laparoscopic techniques. Open surgery involves a larger incision, while minimally invasive methods use smaller incisions and a laparoscope or robotic assistance. The most common types of ileostomy are end and loop ileostomies.
The procedure involves:
- Anesthesia and preparation
- Surgical incisions
- Locating the ileum
- Creation of the stoma
- Closure of incisions and ileostomy pouch placement
Life After Ileostomy: Dietary Guidelines
Initial Post-operative Diet
In the initial weeks following ileostomy surgery, dietary modifications are crucial to facilitate healing and prevent complications. The primary goals are to minimize strain on the digestive system, reduce stool output, and prevent blockages.
Read also: Eating After Ileostomy Reversal
- Small, Frequent Meals: Consuming six small meals throughout the day instead of three larger ones can ease digestion.
- Avoid Overeating in the Evening: This helps prevent discomfort during the night.
- Hydration: Drinking 8 to 10 (8-ounce) glasses of liquids daily is essential to replace fluids lost through the ileostomy and prevent dehydration.
- Bland, Low-Fiber Foods: Focus on cooked, easy-to-digest foods that are not spicy, heavy, or fried.
Examples of Bland, Low-Fiber Foods
- Grains: Refined cereals (such as Cream of Wheat or Rice Krispies), white rice, plain pasta
- Proteins: Tender, well-cooked meats (poultry, fish), eggs (start with small amounts), smooth nut butters (start with small amounts)
- Vegetables: Cooked vegetables without skins (such as carrots, green beans, spinach)
- Fruits: Cooked or canned fruits without skins (such as applesauce, peeled peaches), limited ripe banana (no more than one small banana per day)
- Dairy: Milk, yogurt, cheese
- Fats: Small amounts of butter, margarine, or oil
Foods to Avoid Initially
- Raw Fruits with Thick Skins: Avoid raw fruits with the skin for the first 3 to 4 weeks.
- High-Fiber Foods: Limit high-fiber foods to prevent blockages.
- Gas-Producing Foods: Limit beans, beer, broccoli, cabbage, cauliflower, onions, and carbonated drinks.
- Hard-to-Digest Foods: Limit fresh fruits and raw vegetables initially.
Reintroducing Foods
After the initial recovery period, foods should be reintroduced gradually, one at a time, to identify any intolerances.
- Introduce Foods One at a Time: This helps determine which foods may cause uncomfortable symptoms.
- Monitor for Symptoms: Watch for diarrhea, bloating, gas, or bad odor after introducing a new food.
- Hydration: Maintain adequate fluid intake when adding high-fiber foods back into the diet.
Managing Food Intolerances
Food intolerances can develop after surgery, causing symptoms like diarrhea, bloating, gas, or bad odor. If a food causes uncomfortable symptoms, avoid it for a few weeks and then try it again.
Long-Term Dietary Considerations
- Balanced Diet: A balanced diet that includes a variety of fruits, vegetables, lean proteins, and grains is crucial for overall health and nutrition.
- Hydration: Drink 8 to 10 cups (1.5 to 2 liters) of fluids every day to prevent dehydration.
- Chew Food Thoroughly: Proper chewing aids digestion and prevents blockages.
- Regular Meal Schedule: Eating meals at regular times can help regulate bowel function.
- Limit Gas-Producing Foods: If gas is a problem, limit foods like cucumbers, radishes, sweets, and melons.
- Avoid Sugary Drinks: Limit sugary drinks like juice and soda, and avoid artificial sweeteners.
- Electrolyte Replacement: Consume foods and drinks that contain electrolytes, such as sodium and potassium, to prevent dehydration.
- Vitamin B12: Since Vitamin B12 is absorbed in the terminal ileum and colon, patients with ileostomies are at risk of Vitamin B12 deficiency.
Managing Specific Issues
- Diarrhea: Increase fluid intake, avoid foods that cause diarrhea, and eat foods that can help thicken stool.
- Constipation: Call your doctor’s office.
- Gas and Odor: Talk with your wound, ostomy, and continence (WOC) nurse about managing gas and odor.
Addressing High Output Ileostomies
High output ileostomies (HOI) are a rare but significant complication characterized by excessive fluid and electrolyte loss through the stoma. A high-output stoma is typically defined as a stoma output exceeding 2 liters per day, though some clinicians use a threshold of 1.5 liters over 24 hours. Traditional treatments include anti-diarrheal agents, proton pump inhibitors, and octreotide.
Elemental Diets for High Output Ileostomies
Elemental diets (ED) have emerged as a potential therapeutic option for managing refractory high output ileostomies. These diets provide all essential nutrients in easily absorbed forms, such as free amino acids.
- Mechanism of Action: Elemental diets may reduce inflammation, facilitate nutrient absorption, and alter bacterial flora in the gut, reducing osmotic load.
- Clinical Evidence: Case reports suggest that elemental diets can dramatically reduce ileostomy output and improve quality of life for patients with HOI.
- Application: Elemental diets are considered for patients requiring gastrostomy and those with underlying pancreatic and esophageal diseases.
Dietary Strategies for High Output Stoma
- Limit Hypotonic Fluids: Restrict intake of hypotonic fluids (water, tea, coffee) to 0.5-1.0 L/day to prevent further output increases.
- Consume Glucose-Electrolyte Solutions: Due to the coupled absorption of sodium and glucose in the intestine, patients are advised to consume glucose-electrolyte solutions.
- Limit Simple Sugars: Limiting the intake of foods high in simple sugars (eg, candy, honey, jam, jelly) and high-sugar beverages (eg, fruit juices, sodas) can reduce stoma output and mitigate the risk of dehydration.
- Soluble Fiber Supplements: In cases of persistent high stoma output (>1.5 L/day), the use of soluble fiber supplements or antimotility agents should be considered.
- Foods That Thicken Stool: Patients should be encouraged to consume foods that thicken stool, such as butter, cheese, rice, bananas, pasta, potatoes, noodles, and marshmallows.
The Role of Nutritional Risk Screening
Regular nutritional risk screening is crucial for identifying individuals at risk of malnutrition and facilitating early intervention. The NRS 2002 tool is recommended for nutritional risk screening in patients with ileostomies.
Read also: Managing Weight Loss with an Ileostomy
Monitoring and Assessment
- Frequency: While current guidelines do not specify a precise screening frequency, regular monitoring is essential.
- Parameters: Monitor serum urea, electrolytes, creatinine, and random urine sodium concentration every 1-3 days in the early postoperative period.
- Stool Samples: Collect stool samples for Clostridioides difficile toxin testing in cases of high output.
Practical Tips for Daily Life with an Ileostomy
Stoma Care
- Regular Pouch Changes: Change the ileostomy pouching system every 1 to 4 days initially, then about two times a week at home.
- Skin Protection: Ensure the skin around the stoma is protected from stool contact to prevent irritation.
- Stoma Appearance: The stoma should look red, swollen, and moist; swelling will decrease over time.
Lifestyle Adjustments
- Travel: Pack extra ostomy supplies in a carry-on bag when flying.
- Showering: You can shower with or without the pouching system, avoiding direct spray on the stoma.
- Swimming: Swimsuits with patterns can help conceal the pouch, and the pouching system should be dried well after swimming.
- Clothing: Avoid restrictive clothing and accessories like belts.
- Intimacy: Using a smaller pouch, emptying it beforehand, or covering it with clothing can ease concerns about leaks or odor.
Addressing Common Concerns
- Odor Control: Use odor eliminators or deodorants in the pouch, and consider oral deodorants.
- Gas Management: Eat on a regular schedule, eat slowly, avoid swallowing air, and limit gas-producing foods.
The Elemental Diet Case Study
A 70-year-old lady with ulcerative colitis (UC) treated with a subtotal colectomy ten years prior presented with a high output ileostomy (HOI) refractory to conventional treatment. After initiating an exclusive elemental diet (the 028 diet), her symptoms improved in less than 48 hours, with the frequency of ileostomy bag changes decreasing from 8 times during the day and 5 during the night to 3 times per day with no overnight changes needed. Stomal erosions, excoriations, and bleeding also improved and healed within a few days.
This case suggests that an elemental diet can lead to a dramatic reduction in ileostomy output by reducing inflammation and facilitating nutrient absorption, thereby reducing osmotic load.