Enteritis and an Ileostomy

Enteritis and an Ileostomy

Enteritis and the Ileostomate (published Summer, 2019, The Phoenix)
A sharp ostomy nurse helps a dehydrated patient in another hospital

Susan Bogatin, Ostomy Advocate
Charles Sloan, MSN, RN, CNS-APN, CWON, WCC, OMS

Charles Sloan and Susan Bogatin

There are a lot of articles and online warnings about staying hydrated when you have an ostomy, particularly if you have an ileostomy. However, there are very few articles about what happens once one becomes seriously dehydrated or develops a very dangerous condition related to dehydration. These topics do not get as much attention, and are not well documented for treatment when it happens. This is what happened to me, and I was fortunate to have a WOCN that knew exactly what to do.  My WOCN is Charles Sloan, at Longmont United Hospital.  This article is not intended to teach how to self-diagnose, treat, cure or prevent any disease but to highlight the importance of self advocation and having a relationship with your local WOCN.  The development of an increased volume of ileostomy output should always be assessed immediately by a medical provider and never treated independently.

Simple Stomach Bug?

Susan’s Story:
The day started like any other day. I got up. I had breakfast. It wasn’t until about an hour later while cleaning the kitchen that I realized….uh, oh….I think I’m coming down with something.

The morning went as I expected.  I started to feel achy. Was my nose starting to run a little? My stomach was a little upset, but not too bad. And I was getting tired. All I really needed was a nap and a couple of days to get over this. At that time, who knew that my life could be threatened by a simple stomach bug?

I am the Affiliated Support Group Leader of the Boulder County Ostomy Support Group and have had my ileostomy due to ulcerative colitis for three years, so I thought I was familiar with what to expect.  In the first 24 hours of being sick, my output became predictably greenish-bile as my system cleaned out. But then it quickly changed to a yellow-straw-like color, and the consistency of egg-drop soup.  That was different. And within 48 hours I had no bulk in my output – just yellow water. Lots of yellow water. I tried to stay hydrated using ORS (oral rehydration solutions, H2ORS and Drip Drops), but my stomach was more upset and I was vomiting. I started to notice that it appeared that as much liquid as I was trying to drink, there was even more coming out in my pouch.

Charles’s Analysis:
Susan had developed enteritis with her stomach infection. Enteritis is the inflammation of the small intestine, and it can be caused by multiple factors including viral or bacterial infection, radiation therapy, medication, alcohol or drugs, or inflammatory bowel disease such as ulcerative colitis or Crohn’s disease.  Her enteritis was induced by her viral infection. In this condition, the harmful or poisonous stimuli irritate the intestinal cells, causing them to become swollen and release excess amounts of water and electrolytes, including sodium and chloride ion’s into the ostomy effluent.

First Trip to the Emergency Room

By the morning of Day 3, it was clear I was being affected by my dehydration and I made the first trip to the ER. I expected a rapid infusion of fluids and I would feel much better. Because I’d had so much fluid already filling my pouch, I asked if having the IV fluids would only increase my output. I was assured that the fluids would only affect my tissues and not flow into my pouch. WRONG!! Within 20 minutes my pouch was overflowing, and for the next four hours we had to stop the infusion and unhook everything every 20 minutes to allow me to get to a bathroom to empty my pouch. My poor pouch was not designed for this! After discharge from the ER I got home and, frankly, noticed very little improvement. The IV fluids were all but eliminated in about 4-6 hours. 

Susan was losing large volumes of fluid from two sources: (1) from the viral infection and (2) from the enteritis it was causing.  When an enteritis is occurring the small intestine pulls fluid out of the blood flow.  This is the body’s response at trying to clean up the infection.  The fluid collects in the swelling of the small intestine and this inflammatory response ends up being lost in stool. It was increasing the volume of fluid lost, and contributed even more to Susan’s dehydration.

Back in the Emergency Room


Left: Susan’s normal Hollister #18182 pouch.     Right: High-output Hollister #18012 pouch from the hospital and after coming home.

Thirty-six hours later I was back in the ER, but this time I requested a high-output pouch and I fully expected I would be admitted. A battery of tests were done, and the only positive result was for Astrovirus.  I was admitted to the hospital under infectious-control guidelines.

The Astrovirus is a virus that typically affects children. It is a gastrointestinal infection that results in diarrhea, and can include other symptoms including anorexi, loss of appetite , headache, fever, and vomiting.  Similar to Norovirus infections, there are no treatments to target these infections or a vaccine to prevent them. Within one day, Susan very quickly developed symptoms of diarrhea, vomiting and fatigue.

Kidney’s In Danger

By mid-morning of my second day in the hospital I knew I had to do something different.  I’d been hooked up to an IV with a slower drip, but still had MUCH more liquid output than I was receiving from the IV.  And I wasn’t peeing. My urine was very dark and concentrated. It was noted by the nurses, but nobody in the hospital seemed to know what to do.

As Susan became dehydrated her body’s safety response was to stop making urine.  The fluid that was being lost in her stool and urine is also fluid that helps support blood pressure.  Although stooling and urinating are natural processes that must occur to sustain life, so is maintaining blood pressure. 

When fluid is lost in excess from the body during dehydration, the body either produces more concentrated and smaller volumes of urine or no urine at all in order to maintain blood pressure.  If this dehydration, decreased urine formation, and blood pressure compensation occurs for too long kidney damage can ensue.  The kidneys enjoy making urine in a non-dehydrated state, it is what keeps them healthy.

Starting to Panic

Knowing that nurses were now pointing out the lack of urine output, I frankly started to panic a little. The IV was still running, but I still had more output than I was receiving from the IV. The nurses that had to empty all the containers I was filling were aware of this, but I couldn’t get the Hospitalist to pay attention. So I started reaching out to everyone I knew in the Ostomy Community. I contacted Charles, our local WOCN, my PCP, my GI doc, and even friends in the ostomy community in Southern California with contacts at Keck University Hospital.

The treatment for an acute high output ileostomy will vary from person to person and also be dependent on the cause.  The medical team taking care of an acute high output ileostomy needs to remember that ileostomates either don’t have a colon or have a colon that is not in use which requires more aggressive treatment than a person with a functioning colon and diarrhea would need.  Unlike the colon, the small intestine was not designed to absorb fluid.  Without a colon, the ileostomate is more fragile in regards to dehydration.

WOCN Treatment Plan

Charles quickly got back to me with suggestions:

  • 2-4 mg Imodium, 3x/day with meals and at bedtime
  • Benefiber, for bulk, 3x/day and at bedtime

He also shared recipes for homemade ORS solutions. I called the nurse and asked her to page my doctor so I could share this information, because I really started to feel that time was running short. Two hours later the doctor showed up, and when I told him what I thought I needed his response was skepticism. But I was insistent, and he grudgingly admitted that it probably wouldn’t hurt. Another two hours later I finally got 4 mg Imodium and the Benefiber. Charles told me it would take several hours to see an affect, and up to 36 hours before my output was appearing normal.

A comprehensive treatment plan that could have been provided for Susan while she was in the hospital:

Treatment could have included IV rehydration with a hypertonic solution (hypertonic solutions are 3% saline vs 0.9% saline for isotonic solutions), ORS (oral rehydration solutions), Imodium (loperamide), Benefiber or (cholestyramine), and a PPI (Proton Pump Inhibitor, such as Protonix).

The hypertonic solution prevents the loss of fluid from the inflammation in the small intestine and helps keep the fluid in the circulatory system. Fluids want to follow the higher concentration of electrolytes and sodium in the hypertonic solution, and that helps keep fluids trapped in the body. Oral rehydration solutions function in the same way.

As the ileostomy output begins to decrease and the blood values of electrolytes are stable the intravenous solutions can then be switched to isotonic solutions that contain electrolytes in volumes that are more like normal bodily fluids. Imodium is prescribed in dosages that are usually higher than if prescribed to a person with a colon to slow the movement of the small intestine, allowing for more time to absorb the fluid that is passing through it.  Imodium should also be scaled back as output improves. A PPI decreases gastric secretions, preventing further loss of fluids in the stool.

Sent Home Early

I fully expected to be in the hospital another night, but around 5:30 pm, the doctor came in and asked if I thought it I was OK to go home.  NO, I didn’t think I was, but I was confident that I could continue the protocol from Charles on my own. Charles had told me that as soon as they unhooked the IV that my electrolytes would plummet, so as soon as I got home I downed some concentrated ORS solution (my first attempt made me throw up, so I had to dilute it some) and I continued with the Imodium and Benefiber. Finally, around 3:00 am, my output changed from clear liquid to something like thin gravy. The next morning I lowered the dose of Imodium, but continued with the Benefiber off and on for the next couple of days until I felt things were back to normal.

Two days later I met with my PCP. After reviewing my blood work she was shocked to see how sick I had been. My blood, kidney and liver values while in the hospital had been approaching critical values as a result of the dehydration I had experienced the few days before. Charles told me the best way to heal my kidneys was by drinking lots of fluids and staying hydrated, but it still took two weeks for my kidney labs to return to normal.  It took another week for liver values to return to normal.

Taking Care of Ostomates

Wound ostomy and continence nurses (WOCNs) live, breath, and thrive taking care of ostomates.  Their exposure to ostomates is at a higher volume than that of physician, and to properly care for them they have to continually stay updated when they are off the clock.  They do this by reading current literature in medical journals, complete accredited continuing education credits, maintain relationships with respected colleagues, and attend conferences all related to wound, ostomy, and continence care.  Many physicians may not stay updated in these topics because they do not see high volumes of wound, ostomy, and continence patients. 

Not all communities or hospitals have WOCNs that are easily accessible.  There are only about 8,600 nurses certified by the Wound Ostomy Continence Certification Board in the world, and not all of them are full scope of practice to include the ostomy certification. 

During a time of need an ostomate may be at the mercy of health care providers that are not fully aware of best practices to care for an ostomate.  Because of this ostomates are an underserved population.

Susan’s experience is just one example of the how valuable it can be for an ostomate to know their body, know the available resources to obtain information in a time of need, maintain a relationship with a WOCN, and most importantly advocate for themselves.

Susan Merys Bogatin, Boulder County Ostomy Support GroupBoCoOstomyGroup.com, BoCoOstomyGroup@gmail.com

Charles Sloan, Longmont United Hospital, Longmont, Coloradocharlessloan@centura.org

References

Arenas Villafranca, J. J., López-Rodríguez, C., Abilés, J., Rivera, R., Adán, N. G., & Navarro, P. U. (2015). Protocol for the detection and nutritional management of high-output stomas. Nutrition Journal, 14(45), 2-7. https://doi.org/10.1186/s12937-015-0034-z

Kwiatt, M., & Kawata, M. (2013). Avoidance and management of stomal complications. Clinics in Colon and Rectal Surgery, 6(2), 112-121. https://doi.org/10.1055/s-0033-1348050

Li, W., Stocchi, L., Cherla, D., Liu, G., Agostinelli, A., Delaney, C. P., … Gorgun, E. (2017). Factors associated with hospital readmission following diverting ileostomy creation. Tech Coloproctol, 21, 641–648. https://doi.org/10.1007/s10151-017-1667-z

Raju, D., Sheshagiri, N., Kadarapura, S., & Shenoy, S. (2018). A systematic approach in the management of a high output ileostomy resulting in a favorable clinical outcome. Anesthesiology Case Reports, 1, 1-3.

Venes D (Ed.). (2013). Human astrovirus. In Taber’s Cyclopedic Medical Dictionary (22nd ed.). Retrieved from https://chamberlainuniversity.idm.oclc.org/login?url=https://search.ebscohost.com/login.aspx?direct=true&db=nup&AN=t0hDRV-1240156819&site=eds-live&scope=site