High cost for ostomy

Specialty: Gastrointestinal.

• High ostomy discharge
• hyperfunctioning enterostomy
• ostomy diarrhea

Why it occurs

• Recently created distal enterostomy or ileostomy in phase of incomplete intestinal adaptation (output > 1500-2000 ml in 24 hours)
• Active enteric infection (Clostridioides difficile, Salmonella, Cytomegalovirus) in the remaining intestine
• Sudden suspension of inappropriate antisecretory or prokinetic drugs
• Short bowel syndrome after massive resection with loss of the ileal and colic absorptive surface
• Distal partial obstruction or stenosis of the ostomy mouth that causes hypersecretion due to reflux.

Initial workup

Strict hourly and daily measurement of the effluent volume of the ostomy for 72 hours | Daily analysis: blood count (hemoconcentration), kidney function (plasma urea, creatinine), complete electrolytes (sodium, potassium, chlorine, magnesium, calcium) and venous blood gases | Stool culture and C. difficile toxin from effluent fluid | Barium intestinal transit or abdominal CT to rule out partial obstructions or proximal fistulas.

Standard management

• Loperamide — high doses outside the technical specifications sheet: 4-8 mg administered 30 minutes before the four main meals, to slow down proximal intestinal emptying as much as possible
• Codeine phosphate — 15-30 mg three or four times a day orally, acting synergistically with loperamide on intestinal opiate receptors
• Proton pump inhibitors at high doses — pantoprazole or esomeprazole 40 mg IV or orally every 12 hours to dramatically reduce the volume of gastric secretion entering the small intestine
• Octreotide — 50-100 mcg subcutaneously every 8 hours, indicated in refractory cases to inhibit the secretion of intestinal and pancreatic fluids
• Guided oral rehydration with high-osmolarity WHO formulas or specific intravenous solutions rich in sodium and magnesium.