Following ileostomy surgery, dietary adjustments are necessary to ensure proper nutrition, facilitate healing, and manage stoma output. A low residue diet, characterized by a limited intake of dietary fiber and foods that stimulate bowel activity, is often recommended. This article provides comprehensive guidelines for ileostomy patients on a low residue diet, incorporating evidence-based practices and expert recommendations.
Understanding the Low Residue Diet
The term "residue" refers to the undigested material, primarily dietary fiber, that reaches the large intestine, contributing to fecal bulk. A low residue diet (LRD) restricts dietary fiber to less than 10-15 grams per day. The goal of an LRD is to reduce the size and frequency of bowel movements, alleviating painful symptoms, especially during acute episodes of inflammation or infection.
It's important to note that a LRD is not a long-term solution for inflammatory bowel disease or other chronic conditions and will not decrease inflammation. A physician or dietitian can determine the suitability and duration of this diet for individual patients. When transitioning off a LRD, fiber intake should be gradually increased by approximately 5 grams weekly until the desired fiber goal is reached.
The Role of Diet After Ileostomy
A temporary ileostomy is a surgical procedure used to manage acute conditions like perforated or obstructed colorectal cancer, or in elective rectal cancer surgeries to protect the anastomosis. The creation of a stoma disrupts the natural digestive process, impacting absorption. Ileostomies, located at the terminal ileum, reduce the absorptive surface area, leading to the excretion of undigested food and substantial loss of digestive fluids. This can result in malnutrition, with incidence rates ranging from 40% to 79.09%.
High-output stoma (HOS), defined as a stoma output exceeding 1.5 to 2 liters per day, is a common postoperative complication, leading to readmission rates between 12.9% and 43%. HOS can cause dehydration, electrolyte imbalances, and acute renal failure. Dietary modifications can significantly reduce stoma output in patients with HOS. The ostomy diet plays a vital role in maintaining normal stool characteristics post-surgery, as stool volume, frequency, and consistency are greatly influenced by dietary intake.
Read also: Guide to Low-Residue Cooking
Evidence-Based Dietary Management
This article employs evidence-based nursing methodology to provide systematic recommendations for dietary management in patients with high-output ileostomies. A comprehensive literature search was conducted across multiple databases, including UpToDate, BMJ Best Practice, and Cochrane Library, using keywords such as "Ileostomy/Stoma" and "dietary management." The search covered literature from the inception of each database to January 2024.
Inclusion criteria focused on literature about adult patients undergoing ileostomy surgery, addressing dietary or nutritional management. Eligible research types included clinical decisions, guidelines, evidence summaries, expert consensuses, systematic reviews, and original research closely related to the topic, with studies in Chinese or English. The quality of the included literature was assessed using standardized tools such as the AGREE II tool for guidelines and the JBI Critical Appraisal Checklist for systematic reviews and expert opinions.
Key Aspects of Dietary Management
The research team analyzed and extracted 30 pieces of best evidence, focusing on five key aspects of dietary management for patients with preventive ileostomy:
- Nutritional risk screening
- Monitoring and assessment
- Strategic dietary guidance
- Dietary behavior guidance
- Health education and follow-up
Nutritional Risk Screening
The Nutritional Risk Screening (NRS) 2002 tool is recommended for nutritional risk screening in patients with ileostomy. Patients with an NRS 2002 score ≥3 are considered at nutritional risk and should undergo further nutritional status assessment. Regular implementation of nutritional risk screening and current nutritional status assessment enables timely identification of individuals at risk of malnutrition, facilitating early intervention with individualized, targeted nutritional therapy plans.
Monitoring and Assessment
The normal output volume for an ileostomy ranges from 600 to 1200 mL/day, influenced by fluid intake and food digestion. High-output stoma (HOS) is defined as an output exceeding 1500 mL/day for two consecutive days. Patients typically exhibit weight loss, dry mouth, thirst, reduced urine output, and decreased blood pressure. Regular monitoring of patients’ weight and blood pressure and dietary intake is crucial, and after discharge, the patient should be monitored once every three months.
Read also: Vegetables for a Low-Residue Diet
In the early postoperative period, serum urea, electrolytes, creatinine, and random urine sodium concentration should be monitored every 1-3 days. For hospitalized patients with stable conditions, weekly monitoring is sufficient. Stool samples should be collected for Clostridioides difficile toxin testing in cases of high output, to rule out potential diseases outside of the stoma.
Strategic Dietary Guidance
The restoration of intestinal function following ileostomy typically requires 4-6 weeks. During the early postoperative phase, patients should avoid raw fruits and vegetables. For the first six weeks, cooked or canned fruits are preferred to reduce the risk of diarrhea. High-fiber, viscous, or difficult-to-digest foods such as nuts, corn, celery, asparagus, popcorn, coconut, or mushrooms should be avoided for 6-8 weeks post-surgery.
Patients with ileostomies are at risk of vitamin B12 deficiency, as B12 is a large molecule vitamin primarily absorbed in the terminal ileum and colon. Due to the lack of colonic reabsorption and high stoma output, ileostomy patients may not obtain sufficient micronutrients from their diet alone. Therefore, it is recommended that patients with postoperative nutritional risks or malnutrition continue to receive nutritional therapy for 4-8 weeks post-discharge.
Dietary Behavior Guidance
Patients with ileostomies should increase their daily fluid intake by 500-750 mL above the average recommended intake for the general population, prioritizing water, broth, vegetable juice, and some sports drinks. 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.
Patients should chew food thoroughly and introduce new foods gradually, starting 6-8 weeks post-surgery. It is recommended to introduce one new food item every three days in small quantities, while monitoring for any adverse reactions. Patients are advised to consume small quantities of potentially obstructing foods and chew thoroughly. Common “obstructive foods” include popcorn, coconut, mushrooms, black olives, high-fiber vegetables, corn, nuts, celery, foods with skin, dried fruits, and meats with casings. Drink water between meals, and limit fluid intake 30 minutes before and after meals.
Read also: Understanding the Low-Residue Diet
Health Education and Follow-Up
Stoma specialist nurses should intensify follow-up care, with a recommendation for continuous monitoring of intake and stoma output for 4 weeks to reduce the risk of dehydration and electrolyte imbalances. Concurrently, healthcare professionals should prioritize patient education prior to discharge. Patients and their families should be informed about the importance of adhering to dietary guidelines, recognizing signs of dehydration and electrolyte imbalances, and managing potential complications such as stoma obstruction.
Practical Dietary Recommendations
General Guidelines
- Eat small meals often: Try to have 6 small meals throughout the day instead of 3 large ones.
- Don’t eat too much in the evening.
- Chew food well to prevent blockages from a food bolus.
- Drink 6-8 cups of fluid a day. If you suffer from constipation make sure to increase your fluid intake.
- Exercise caution when reintroducing foods into your diet following surgery. When you add foods back into your diet, reintroduce them one at a time and monitor your body's reaction. The goal is to eat the way you did before surgery, however, if some food items cause unpleasant digestive symptoms, you may need to eliminate them.
- Taking a supplement may be beneficial if you have a deficiency.
Foods to Include
- Grains: Choose grains with less than 2g of fiber per serving like refined white breads and cereals (e.g. puffed rice, corn flakes), farina, white pasta, and crackers.
- Milk products: Choose up to 2 cups of low-fat milk products including yogurt, cottage cheese, buttermilk, kefir or sherbet. Avoid all milk-containing products if you are lactose intolerant. Low-lactose cheese is also a good option.
- Vegetables:
- Raw (in small quantities at first): Lettuce (shredded), Cucumbers (without seeds or skin), Zucchini.
- Well-cooked or canned (without seeds and without skin): Yellow squash (without seeds), Spinach, Pumpkin, Eggplant, Potatoes (without skin), Green beans, Wax beans, Asparagus, Carrots.
- Fruits: Fruit juices without pulp and many canned fruits or fruit sauces, such as applesauce. Raw fruits you can have are very ripe apricots, bananas (limit to 1 small ripe banana per day in the first 3-4 weeks), cantaloupe, honeydew melon, watermelon, nectarines, papayas, peaches, and plums.
- Protein: Cooked meat, fish, poultry, eggs, smooth peanut butter, and tofu. Make sure your meats are tender and soft, not chewy with gristle.
- Fats, oils, and sauces: Butter, margarine, oils, mayonnaise, whipped cream, and smooth sauces and dressings. Smooth condiments are acceptable.
- Other: Foods that thicken stool, such as butter, cheese, rice, bananas, pasta, potatoes, noodles, and marshmallows.
Foods to Limit or Avoid
- High-fiber foods: Beans and legumes, Whole grains, Many raw vegetables and fruits, Fruit and vegetable skins, Nuts and seeds, The connective tissues of meats.
- Foods that may cause gas or air: Onion, garlic, legumes (e.g. beans, lentils), broccoli, cabbage, Brussels sprouts, cauliflower, carbonated beverages, beer, spinach, bean sprouts, and coffee.
- Foods that may cause increased diarrhoea: Spicy foods.
- Foods that may cause blockages: Popcorn, coconut, mushrooms, black olives, high-fiber vegetables, corn, nuts, celery, foods with skin, dried fruits, and meats with casings.
- Other: Deli meats, hot dogs, sausage, crunchy peanut butter, nuts, beans, tempeh, and peas. Avoid fruits canned in heavy syrup. Avoid canned and raw pineapple, fresh figs, berries, all dried fruits, fruit seeds, and prunes and prune juice. Don't eat very spicy or acidic foods and dressings. Avoid chunky relishes and pickles. Don't eat deep-fried foods. Don't eat desserts that have nuts, coconut, or fruits that are not OK to eat.
Fluid Intake
- Drink 8 to 10 (8-ounce) glasses (about 2 liters) of liquids every day.
- Drink water between meals, and limit fluid intake 30 minutes before and after meals.
- Don’t drink more than 4 ounces (½ cup) of liquids with meals. Don’t drink any liquids for 1 hour before and 1 hour after meals.
- Drink sports drinks (such as Gatorade or Powerade) and oral rehydration solutions (such as Pedialyte).
- Limit or avoid the following foods and drinks. If you drink coffee, choose a dark roast instead of a light roast. Limit the amount of alcohol you drink for the first 3 weeks after your surgery. Don’t drink sugary drinks, such as juice and soda. If you want to drink juice, choose 100% fruit juice and dilute it (mix it with water) to reduce the sugar. Don’t have artificial sweeteners, such as sorbitol, mannitol, and xylitol.
Managing Common Ileostomy Problems
Dehydration
- Signs of dehydration: Decreased urine output, dark urine, dry mouth, dizziness, and fatigue.
- Recommendations: Increase fluid intake, especially water, broth, and sports drinks. Limit hypotonic fluid intake to 0.5-1.0 L/day for patients with stoma output exceeding 1.5-2.0 L/day. Consume glucose-electrolyte solutions.
High Output
- Definition: Stoma output exceeding 1500 mL/day for two consecutive days.
- Recommendations: Limit intake of simple sugars and high-sugar beverages. Consider soluble fiber supplements or antimotility agents in cases of persistent high stoma output.
Stoma Obstruction
- Symptoms: No gas or bowel movements coming from your stoma for 6 hours and you have cramps, pain, nausea (feeling like you’re going to throw up), or all 3.
- Recommendations: Avoid potentially obstructing foods, chew food thoroughly, and consume small quantities of these foods. Don’t take a laxative.
Diarrhea
- Recommendations: Drink 8 to 10 (8-ounce) glasses (about 2 liters) of liquids throughout the day. Avoid foods and drinks that may cause diarrhea. Eat more of the foods that thicken stool.
Gas and Odor
- Recommendations: Limit or avoid gas-producing foods. Avoid using straws, talking while eating, and chewing gum to reduce air ingestion. Eat less of the foods that cause gas and odor. Eat more of the foods that help reduce gas and odor.
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