Information for people with a high output stoma

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The aim of this leaflet is to help you manage your high output stoma.
This advice relates to your diet, drinks, and prescribed medications. It has been written by the Dietitians, the Nutrition Support Team and the Stoma Care Nursing Team.
The advice here will help slow down food and fluids going through your gut to improve absorption of water and nutrients. The advice summarised here will help reduce the risk of dehydration and malnutrition and keep you feeling well.
If you feel unwell and consistently notice any of the signs and symptoms listed on the next page, contact your GP or call 111 (NHS non emergency number) for advice. In an emergency, go to A and E.

What is a high output stoma?

A high output stoma is a stoma that passes more than one to 1.5 litres of stoma output in a 24 hour period.
High output is commonly associated with an ileostomy.

Why do I a have a high output stoma?

Your stoma may be high up in the small bowel, so not enough of the small bowel length is available to absorb water and salts OR
You might have a temporary functional bowel disorder increasing your stoma output i.e. the bowel is present but not working correctly.

What concerns are associated with a high output stoma?

Dehydration (either long or short term) and malnutrition.
Salt imbalances.
Medication may not be absorbed (see ‘Managing your high output stoma: medicines’ below).
Nausea / vomiting.

Signs and symptoms of a high output stoma

Watery stoma output.
Changing your stoma bag more often than usual.
Possible leaking of stoma bags.
Becoming dizzy when standing up (related to low blood pressure).
Having a dry and sticky mouth.
Sunken eyes.
Passing a reduced volume of urine (that may be dark in colour and strong smelling).
Headache.
Lethargy, tiredness and feeling low in mood.
Cramps in your hands and feet.

Managing your high output stoma: drinks

Restrict ‘ordinary drinks’ to one litre per 24 hours

‘Ordinary drinks’ include water, squash, tea, coffee, hot chocolate, milk, fruit juice, fizzy drinks and nutritional supplement drinks. They pass through your gut very quickly and draw fluid and salt out of your body.
You may feel thirsty, but drinking more of these drinks will lead to further fluid and salt loss from your body, causing dehydration.

Separate foods and fluids

This can help slow down the passage of food through your gut.
If you avoid drinking (or only take very small sips) at meal times this can help you keep within your ‘ordinary drinks’ allowance as well.

Ideas to help you stay within your fluid allowance

Use small cups, glasses or beakers for ordinary drinks.
Suck ice cubes if you are thirsty. Use rehydration solution (see ‘Managing your high output stoma: rehydration drinks’ below) to take your tablets.

Managing your high output stoma: rehydration drinks

If you have been advised to limit ‘ordinary drinks’, you also need to drink a rehydration drink to ensure you stay hydrated. You should drink one litre per 24 hours, split into e.g. five drinks through the day.
Rehydration drinks replace both salt and fluid in a way that your body can absorb more easily.
Rehydration drinks may also be called ‘electrolyte mix’ or ‘St Mark’s solution’. Alternatively you may be advised to make up Dioralyte to double strength (using two sachets in place of one).
In total, with your 1 litre ‘ordinary drinks’ allowance, you will be drinking a total of two litres of fluid per 24 hours.
For directions on preparing St Mark’s solution, see ‘St Mark’s solution recipe’ page below.

Managing your high output stoma: diet

Add salt to food

Your body is continually losing salt. You can replace it by:

Using salt in cooking and adding salt to your meals.
Choosing salty foods and snacks such as cheese, bacon, ham, sausages, smoked fish, canned fish, meat and fish pastes, tinned foods such as spaghetti and ravioli, meat and yeast extracts, stock cubes, salted crisps, savoury biscuits and crackers.

Have a diet low in insoluble fibre

Dietary fibre is the part of plant foods that our digestive system is not able to break down. ‘Soluble’ fibre dissolves in water forming a gel in the digestive system helping to slow down bowel movements. ‘Insoluble’ fibre does not absorb water and it tends to speed up the passage of food through your bowel. Choosing foods low in insoluble fibre means you’ll be better able to tolerate larger portions of energy-rich foods, that these foods will pass more slowly through your gut, and that stool bulk will be lower.

Making changes to your diet

When your stoma output is high, reducing the amount of insoluble fibre in your diet can help manage your stoma output. The aim of this diet is to reduce the bulk from poorly or partially digested matter passing through the gut.

Once your stoma output reduces / thickens, you can gradually return to your usual diet. When you no longer need to be on a low insoluble fibre diet, increase your fibre intake gradually over a few days.

Other useful tips

Eat little and often: smaller meals with snacks between meals.
Chew food well.
To ensure you get enough vitamin C, consider including a small glass of fruit juice or vitamin C-enriched squash daily.
Some people find high-fat foods and / or spicy foods are poorly tolerated and therefore may be best avoided.
Caffeine can increase the speed at which foods and fluids move through the bowel. Consider choosing decaffeinated drinks.
Avoid sorbitol, xylitol or mannitol (sweeteners) or foods and sweets that contain them. They can increase your stoma output and cause wind / bloating.
If you are on the low insoluble fibre diet long term, and are unable to manage five portions of fruits and vegetables a day (including up to one glass of fruit juice), you may need a multivitamin and mineral supplement. Your doctor, GP or dietitian can advise.
Some people find that foods containing gelatine (fruit gums, jelly, marshmallows, jelly babies) may help thicken their stoma output.

The following highlights changes you can make to reduce the amount of insoluble fibre in your diet.

Breads, flour, rice, pasta

CHOOSE: White flour bread, bagels, rolls and pitta, Chapattis and Naan bread made with white flour ,White rice and rice cakes,White pasta,Cornflour, Semolina, tapioca, sago, Cous cous, polenta,Tortillas and tacos made with white flour.

AVOID: Brown, wholemeal and granary bread, rolls and pitta, Chapattis and Naan bread made with brown / wholemeal flour, Brown and wild rice,Rye, multigrain and breads with added nuts and seeds,Wholemeal pasta and pastry,Popcorn and corn chips.

Cereals

CHOOSE: Cornflakes, Frosties, Rice Krispies, Coco Pops, Porridge (oats), Ready Brek, Ricicles,Special K

AVOID: Branflakes, Weetabix, All Bran, Shredded Wheat, Muesli, granola or cereal with added dried fruit or nuts.

Biscuits, cakes, crackers, sweets and chocolate

CHOOSE: Savoury and sweet biscuits made with white flour e.g. water biscuits, cream crackers, cheese straws, Rich Tea, custard creams, shortbread,Plain scones, sponge cake. Oat cakes, flapjack, cereal bars without nuts and dried fruit,Chocolate and sweets without fruit, nuts or seeds.

AVOID: Ryvita, Twiglets, Hovis wholemeal biscuits, Digestives, Hobnobs, Fig rolls, mince pies, Fruit scones, malt loaf,Genoa,Snickers, Topic, M&M peanut,nougat, peanut brittle, Popcorn.

Milk and dairy products

CHOOSE: Milk, cheese (hard and soft),Smooth yoghurts, Crème fraiche, sour cream,
fromage frais, Eggs

AVOID: Cheese with added nut or dried fruit e.g. Wensleydale with Cranberry, Yoghurt with whole fruit or added dried fruit, nuts or muesli.

Fruit

Limit to 3 portions a day plus a glass of fruit or vegetable juice.

CHOOSE: Tinned, fresh or stewed fruit without the skins, seeds or pips e.g. stewed apple, peeled poached pear, ripe banana,sliced fresh mango, ½ avocado, grapefruit or orange segments with pith removed, Smooth fruit juice without ‘bits’.

AVOID: All fruits with skin, pith, seeds e.g. raspberries, blackcurrants, gooseberries, grapes, rhubarb, cherries, figs, Unripe (green) bananas, Coconut, Dried fruit e.g. raisins, dates, sultanas, cranberries, prunes, Smoothies, fruit juice with pulp.

Vegetables

Make up (with fruit) to 5 portions of fruit and vegetables a day (excluding potato).

CHOOSE: Canned, processed or well cooked vegetables e.g. carrots, mushrooms (finely chopped), swede, butternut squash, courgette, cauliflower,broccoli, aubergine (avoid skins, stalks and seeds), Lettuce, pepper, cucumber,bean sprouts, tomatoes (no skin or pips), White and sweet potatoes without their skins e.g. mash,chips, sauté, crisps, the inside (i.e. no skin) of a jacket potato,Passatta and smooth vegetable juices.

AVOID: Raw vegetable e.g. coleslaw, Aduki, blackeye, broad, butter, mung, kidney and soya beans, Lentils, chickpeas, hummus,Green beans, mange tout, peas, sweetcorn, Cabbage, spring greens, chard, artichokes, Salad ingredients not listed in the allowed column, Jacket potato with the skin and new potatoes,Vegetable juice with pulp.

Meat, fish and alternative protein sources

CHOOSE: All meat, poultry and fish, Tofu.

AVOID: Meat, fish or poultry made with wholemeal / brown pastry or breadcrumbs, Quorn, TVP, Nuts, seeds and peanut butter.

Fat and oils

CHOOSE: Butter, margarine and oils, Mayonnaise, salad cream, Salad dressing.

AVOID: Salad dressing with whole nuts or seeds.

Miscellaneous

CHOOSE: Seedless, rind-less jams / marmalades, lemon curd and jellies, Marmite, stocks, seasoning, herbs and spices.

AVOID: Shredded marmalade, whole fruit and seeded jams, Peanut butter, pickles and chutney.

If you need to follow this diet for a longer period of time your medical / surgical team or dietitian will advise you.

Managing your high output stoma: medicines

Loperamide tablets*

Used to slow the movements of the bowel to allow fluid and nutrition more time to be absorbed into the body. Take 30 minutes before food Can be taken up to four times per day . Avoid capsules.