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An Overview of Ostomies and

the High-Output Ostomy
Article in Hospital Medicine Clinics October 2013
DOI: 10.1016/j.ehmc.2013.06.001

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An Overview of Ostomies and the

High-Output Ostomy
Bilal Gondal,

MD, MRCSI,

Meghna C. Trivedi,

MD*

KEYWORDS
 Stoma output  Ileostomy  Colostomy  Management of stomas  Nutrition support
 High-output stoma

HOSPITAL MEDICINE CLINICS CHECKLIST

1. A high-output stoma (HOS) is defined as greater than 2 L of output from the

stoma in a 24-hour period.
2. Jejunostomy is a HOS. Jejunum ranges in length from 200 to 300 cm, and
greater than 90% of nutrient absorption occurs in first 100 to 150 cm of the
intestines.
3. Clinical assessment of a patient with HOS focuses on identifying and correcting
fluid and electrolyte disturbances, and optimizing nutritional status.
4. It is a common mistake to encourage patients with a HOS to drink large
amounts of hypotonic fluids. Use Oral Rehydration Solution or other isotonic
solutions for fluid replacement.
5. Greater than 50 cm of functioning bowel is required for absorption of an oral
proton-pump inhibitor.
6. Dietary modifications play an important role in decreasing the stomal output.
7. Correction of sodium and water depletion, oral or intravenous supplementation
of magnesium, and vitamin D analogue have been used to correct hypomagnesemia, which is a problematic complication of HOS.
8. A multidisciplinary team approach is vital to enhance the quality of life of
patients with an ostomy.

DEFINITIONS

1. What is a stoma and what are the different types of stomas?

An ostomy is a surgically made opening from the inside of an organ to the outside.1
Stomas may be temporary or permanent. Temporary stomas are usually reversed at
Department of Medicine, UMass Memorial Medical Center, 119 Belmont Street, Worcester, MA
01605, USA
* Corresponding author.
E-mail address: Meghna.Trivedi@umassmemorial.org
Hosp Med Clin 2 (2013) e542e551
http://dx.doi.org/10.1016/j.ehmc.2013.06.001
2211-5943/13/$ see front matter 2013 Elsevier Inc. All rights reserved.

High-Output Ostomy

a later date, allowing the blind loop of intestine to be used once again and, more importantly, eliminating the need for an ostomy, allowing the patient to defecate normally.
Types:
 Gastrostomy and jejunostomy: openings between the abdominal wall and stomach or jejunum, respectively. These openings are used predominantly for enteral
feeding tubes.
 Ileostomy: opening from the small intestine to the abdominal wall so that feces
bypass the large intestine and the anal canal.
 Colostomy: opening from the large intestine to the abdominal wall so that feces
bypass the anal canal.
 Urostomy: connection between the urinary tract and abdominal wall leading to a
urinary conduit so urine passes straight into a stoma bag and thus bypasses
the urethra.
2. What is the typical ostomy output/stool output in different types of resections?
 Jejunostomy: A jejunostomy is a high-output fecal stoma and can have up to
6 L/d of stomal output. The jejunum is a major organ for nutrient absorption
(most fats, proteins, vitamins, and carbohydrates not already absorbed in the
stomach and duodenum).2 It is important to emphasize to patients that they
should limit the oral intake of fluids or a vicious cycle may begin. A jejunostomy
tube placed for feeding should be clamped when not in use, not left to drain.
 Ileostomy: Initially 1200 mL/d which then decreases to about 600 mL/d. During
the early postoperative period and episodes of gastroenteritis, daily output can
be 1800 mL or even higher.3
 Colostomy: 200 to 600 mL/d (Table 1).
3. What is a high-output stoma?
Normally in a healthy adult, about 4 L of intestinal secretions (0.5 L saliva, 2 L gastric
acid, and 1.5 L pancreaticobiliary secretions) are produced in response to food and
Table 1
Characteristics of different types of ostomies
Type of Ostomy

Location

Type of Discharge

Patient Problems

Ileostomy

Right lower
quadrant

Liquid or paste like

Continuous drainage
Contains digestive
enzymes

Skin protection
Odorous
Dehydration
Food blockage

Ascending colostomy

Middle or right
upper abdomen

Liquid or semisolid
Contains digestive
enzymes

Skin protection
Odorous
Dehydration
Gas control

Transverse colostomy

Center of abdomen,
higher side

Semisolid
Frequent drainage
May contain
digestive enzymes

Skin protection
Odorous
Gas control

Descending colostomy
or sigmoid colostomy

Left lower quadrant

Normal stool
Odorous

Skin protection
Odorous
Gas control

Adapted from Hollister, Inc. Types of ostomies. Libertyville (IL): 1992.

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drink each day.4 A high-output stoma (HOS) is defined as greater than 2 L (8 cups) of
fluid from the ostomy in a 24-hour period.
STOMA COMPLICATIONS

 Peristomal skin breakdown: Mechanical breakdown (from adhesives, cleaning

agents), exposure to effluent fluids (eg, from poorly fitting appliances), or allergic
reaction to pouch
 Parastomal hernia formation: Especially common among colostomies.5,6 Risk
factors include obesity, poor abdominal muscle tone, and chronic cough
 Peristomal infection, abscess or fistula formation: Relatively uncommon in early
postoperative period. Reported incidence of these complications is 2% to 14.8%7
 Stomal stenosis: Narrowing of the stoma, which might need surgical revision
 Stomal necrosis: Occurs perioperatively as a result of venous congestion or
arterial insufficiency from a tight fascial opening. The incidence of early stomal
necrosis is reported to range from 2.3% to 17%7
 Retraction: Occurs commonly with obesity or weight gain after surgery
 Stomal prolapse: Occurs with elevated intra-abdominal pressures, more common in transverse loop colostomies and end colostomies
CAUSES OF HIGH-OUTPUT STOMA










Intra-abdominal sepsis
Surgery leaving less than 200 cm residual small bowel and no remaining colon
Obstruction in intestine at stoma site or proximal
Infection of the intestine (eg, Clostridium difficile). Methicillin-resistant Staphylococcus aureus enteritis is also reported to cause a high stoma output in the early
postoperative period after bowel surgery8
Active Crohn disease
Radiation enteritis
Withdrawal of medications, such as steroids or opiates
Administration of certain prokinetic medications (eg, metoclopramide, erythromycin, or laxatives). Metformin has also been shown to cause increased stomal
output9

HISTORY AND EXAMINATION

1. What are the features of a healthy stoma?

 The stoma is located above the skin level, and is red and moist (pallor can suggest anemia, whereas a dark hue may indicate ischemia). Immediately postoperatively, it looks swollen. The swelling subsides within 6 weeks. Patients need to
be reassured that a red stoma is a healthy stoma. The patient should not report
pain or other discomfort associated with the intestinal stoma, as there are no
somatic nerve endings in bowel.
 There is no separation between the mucocutaneous edge and the skin.
 There is no erythema, ulceration, rash, or inflammation in the surrounding skin.
2. What are signs and symptoms seen in patients with HOS?
 Patients with HOS present with watery stool and report emptying the stomal
pouch/appliance more than 8 to 10 times per day. The output may be difficult

High-Output Ostomy

to contain and may cause leakage. Patients may complain of dry mouth,
increased thirst, fatigue, light-headedness, shortness of breath, muscle cramps,
or abdominal cramping. It is important to evaluate these patients for signs of
dehydration and electrolyte disturbances. Hyponatremia, hypokalemia, and hypomagnesemia are commonly noted in these patients.10 Dehydration can lead
to renal failure.
 HOS puts patients at risk of malnutrition. Patients complain of feeling fatigued or
dizzy; they may have unintentional weight loss, impaired wound healing (due to
protein-energy malnutrition and inadequate micronutrients), and easy bruisability
(due to vitamin deficiency or malabsorption).
3. What are the psychological effects of having a stoma?
Anxiety and depression are commonly seen; ostomies may contribute to perceived
reduced quality of life. It is crucial to prepare patients undergoing stoma formation
with educational materials and one-on-one counseling with a mental health specialist.
Introducing patients to other patients who already live with an ostomy may also be
valuable. The first few weeks post stoma are the most vital. Patients frequently have
difficulty managing their stoma while performing daily activities (eg, shopping), and
changing bags without necessary facilities. Patients may experience a change in
body image, and intimate relationships may suffer.11,12
Phantom rectum may occur during the first weeks after a colostomy or ileostomy,
whereby patients may experience sudden urges to defecate. In this case the patient
may require reassurance and support, as this can be very distressing.
MANAGEMENT

1. Which adults with HOS should be hospitalized?

Patients with moderate to severe dehydration and renal failure need hospitalization.
These patients are kept NPO (nothing by mouth) and are hydrated with 0.9% saline
(24 L/d). After 2 to 3 days of intravenous hydration, food and restricted fluids up to
500 mL are introduced while slowly weaning intravenous fluids.13 Strict input and
output should be recorded. Urine output should measure at least 800 mL/d with a
sodium concentration greater than 20 mmol/L.
Weight should be followed daily. Serum electrolytes and renal function should be
measured on a regular basis. Electrolytes should be repleted appropriately. It is
important to identify the cause of HOS and to treat the underlying cause as early as
possible.
2. What are the goals of management?
The 4 important principles on which management of high-output stoma should be
based are as follows:





Correct dehydration and electrolyte imbalance

Reduce stoma output by pharmacologic and nonpharmacologic methods
Identify and treat the underlying cause of HOS
Act as quickly as possible to prevent complications

Patients should be linked with a nutrition counselor who has experience in managing
these complex patients. A multidisciplinary approach to management of HOS should

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be undertaken. It should include the patient and his or her family, a nutritionist, the
patients surgeon, and potentially other health care providers.

3. What pharmacologic strategies can be used in patients with high-output stoma?

A conservative approach is used initially. If it fails to improve the patients
clinical condition, medications to decrease the amount of stool output are used.
The most commonly used medications are proton-pump inhibitors and antidiarrheal
medications such as loperamide (Imodium) and diphenoxylate/atropine (Lomotil).
a. Proton-pump inhibitors
Proton-pump inhibitors work by covalently binding to the H1K1-ATPase system
at the secretory surface of gastric parietal cells. This action suppresses the final
step in gastric acid production, and leads to inhibition of both basal and stimulated
acid secretion.
Gastric hypersecretion may occur in the first 2 weeks after bowel resection, but
may also occur over a longer period of time.14 In the immediate postoperative
period, it has been recommended to use a pantoprazole drip (80 mg bolus followed
by 8 mg/h).15 Once oral intake is started, proton-pump inhibitors are used orally.
Omeprazole, 20 mg twice a day, may be used to reduce hypersecretion.16 It is
important to bear in mind that greater than 50 cm of functioning jejunum is required
for absorption of oral proton-pump inhibitors.17
b. Loperamide (Imodium)
Loperamide slows transit time, resulting in decreased intestinal output. Loperamide can be used in patients with HOS to reduce bowel movements to 1 to 3 times
per day. The patient should be advised to take 24 mg of loperamide 30 minutes
before meals and at bedtime. The patient should be advised not to exceed
8 mg/d (over-the-counter dose) and 16 mg/d (prescription dose).15
c. Diphenoxylate-atropine (Lomotil)
If loperamide is not effective, codeine phosphate or diphenoxylate-atropine may
be used. Diphenoxylate-atropine has a relaxation effect on intestinal smooth muscles and thereby reduces intestinal output by 20% to 30%.1820 Diphenoxylate
has central opiate effects and an increased risk of overdose. It is chemically related
to some narcotics, and may be habit forming if taken in quantities larger than prescribed. Atropine may cause anticholinergic side effects. Diphenoxylate-atropine
is available as 4-mg tablets, and the recommended dose is 2 tablets 4 times per
day.17 If any tablets/capsules emerge unchanged in stool/stomal output, tablets/
capsules can be crushed, opened, and/or mixed with water or put on food. Liquid
formulations are also available.
d. Codeine phosphate and tincture of opium are used if loperamide and
diphenoxylate-atropine are not effective.
e. Somatostatin/octreotide
Octreotide is a synthetic analogue of hormone somatostatin.
Octreotide decreases intestinal output by 3 mechanisms:
 It inhibits the release of gastrointestinal hormones, namely gastrin, cholecystokinin, secretin, motilin, and other hormones. This inhibition decreases the secretion of water, bicarbonate, and pancreatic enzymes into the intestine, thus
decreasing the intestinal volume.21
 Octreotide relaxes the intestinal smooth muscles, thereby allowing for an
increased intestinal capacity.
 It increases intestinal water and electrolyte absorption.22

High-Output Ostomy

 Octreotide is dosed 50 to 250 mg subcutaneously 3 to 4 times per day. It may be

needed if there is insufficient length of remaining jejunum (<50 cm) to absorb a
proton-pump inhibitor in patients with jejunostomy.
 SMS 201-995 is a very potent analogue of somatostatin that has been shown to
decrease proximal ileostomy output.23
f. Clonidine
Clonidine has been shown to reduce intestinal output in patients with HOS or
short bowel syndrome with high output refractory to treatment with antidiarrheals
and antisecretory agents. Clonidine has been shown to significantly reduce output,
thus limiting the need for parenteral nutrition and intravenous fluids. The recommended dose is 0.1 to 0.3 mg up to 3 times per day.24
g. Steroids/fludrocortisone:
Oral fludricortisone, high-dose hydrocortisone, or intravenous aldosterone each
has been shown to occasionally reduce stomal output in patients with functioning
ileum. Fludricortisone increases ileal sodium absorption.25,26
4. What nonpharmacologic strategies should be used in patients when they initially
experience increasing volume output of their stoma?
 The patient should be instructed to avoid drinking hypotonic fluids and beverages such as tea, coffee, alcohol, and fruit juices, and avoid foods containing
high amounts of sugar.
 Oral input and stomal output should be monitored closely. Adequate urine output
(0.5 mL/kg/h) should be maintained.
 Oral Rehydration Solution (ORS) is recommended to prevent dehydration. The
World Health Organization recommended ORS consists of 3.5 g sodium chloride,
2.5 g sodium bicarbonate, 1.5 g potassium chloride, and 20 g of mixture in 1 L of
potable water. This drink can be easily prepared by mixing 8 teaspoons of sugar,
1 teaspoon of salt, and 1 cup of orange juice in 1 L of drinking water. Patients are
encouraged to sip at least 1 L of this solution at frequent intervals.
 Alternative such as Pedialyte, Rehydralyte, and Ceralyte are good hydration
solutions for patients with a HOS.
 Gatorade G2 with one-eighth teaspoon of salt added to every 8 ounces of the
drink is another good alternative to ORS.
 Patients should eat small meals every 2 to 3 hours or 6 to 8 times a day for better
digestion and absorption, and include foods that may help thicken stools. The list
of foods is provided in the next section.
 Starch and protein-rich food slow the transit time, thus providing the body more
time for digestion.
 Reducing lactose in the diet helps to decrease bloating and diarrhea.
 Salt should be used liberally.
 High-fiber food and food with skins and roughage that may increase output
should be avoided.
5. Which foods decrease the amount of diarrhea/ostomy output?
 In general, complex carbohydrates should be consumed, as they slow down the
transit time through the intestine and provide bulk to the stool. Foods that are rich
in complex carbohydrates are pasta (white), bread (white), grains, rice (white),
potatoes, fruits (apples, bananas), and vegetables without skin.
 Foods such as tapioca pudding, creamy peanut butter, almond butter, potatoes
(without skin), oatmeal, and apple sauce help thicken foods and limit the stomal
output.

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6. Which foods increase the amount of diarrhea/ostomy output?

 Simple carbohydrates such as honey, sugar, corn syrup, soda, chocolates, jams,
jellies, and so forth increase the amount of water in intestines secondary to
osmotic effect, and increase the amount of ostomy output.
 Sugar-free products containing sorbitol, mannitol, or xylitol should be avoided,
as they can worsen diarrhea.
 Beverages containing caffeine, such as coffee, tea, cola, and alcohol, are stimulants that increase stool output.
 Juices, especially apple, grape, and prune juice, are high in sugar and cause
diarrhea.
 Juices with pulp, dried fruits such as raisins and pineapple, frozen berries, and
coconut should be avoided.
 Raw vegetables, corn, popcorn, potato skins, stir-fried vegetables, peas, beans,
legumes, and salads should be avoided during the period of high ostomy output,
as they are high in fiber and increase the stool output (Table 2).
7. How should hypomagnesemia be managed?
Magnesium depletion is an important electrolyte derangement in patients with jejunostomy. Sodium depletion causes secondary hyperaldosteronism, thereby affecting
magnesium balance. Patients may become symptomatic with a serum magnesium
level of less than 0.6 mmol/L. Patients may suffer from fatigue, muscle weakness,
dizziness, nausea, vomiting, and muscle cramps.
Water and sodium depletion should be corrected to correct hypomagnesemia. Oral
magnesium in the form of magnesium oxide is used as gelatin capsules of 4 mmol to a
total of 12 to 24 mmol/d.13 It does not appear to increase stomal output. Magnesium
oxide is usually taken at night when transit time is slowest and can be maximally
absorbed.
If oral magnesium oxide fails to increase magnesium to optimal levels, 1a-hydroxycholecalciferol in increasing doses can be used. Oral 1a-hydroxycholecalciferol

Table 2
Dietary recommendations for patients with ostomy
Food

Reason

Eat meals in small amounts frequently, every

2 or 3 h or 68 times a day

Prevents bloating
Helps digestion and absorption
Helps meet nutritional needs

Include foods in diet that thickens stool

Helps decrease stool output

Include starchy foods like white rice, white

pasta, bread, cereal, and potatoes
Include protein foods including fish, meat,
eggs, cheese, and peanut butter

These foods slow the movement of food

through intestines, giving the body more
time for digestion

Include salty snacks like crackers, chips,

pretzels

Helps absorb fluids better

Reduce lactose in diet

Reduces bloating and diarrhea

Avoid high-fiber diet like whole grains and

food with membranes

Reduces bloating and diarrhea, helps

decrease stool output

Avoid foods high in sugar like jams, jellies,

honey, white and brown sugar, molasses

Reduces diarrhea/stool output

High-Output Ostomy

increases intestinal and renal absorption of magnesium. The dose of 0.25 to 9 mg daily
is gradually increased (every 24 weeks in 0.25-mg increments) while ensuring that
hypercalcemia does not occur.27 Magnesium can also be administered in intravenous
infusions with saline.
PERFORMANCE IMPROVEMENT

There is no specific performance improvement measure related to management of

HOS. However, several practices may be associated with improved outcomes:
 A multidisciplinary approach to the management of patients with stoma is very
important in enhancing the patients quality of life. This multidisciplinary team
includes the colorectal surgeon, wound ostomy continence nurse, nutritionist,
patient, and family members involved in the care of the patient
 Use of ORS instead of hypotonic fluids when the patient becomes dehydrated
 Early intervention or hospitalization when the patient develops high output and
signs/symptoms of dehydration
 Concurrent attention to the psychological needs of the patient with an ostomy
The United Ostomy Association of America (UOAA) is a national organization that
provides support, information, and advocacy to patients with ostomy and their caregivers. The UOAA is a member of the International Ostomy Association. The UOAA
Web site is a useful online resource for patients with ostomy, with discussion boards,
support groups, and general information for patients.
CLINICAL GUIDELINES

Nightingale J, Woodward JM. Guidelines for the management of patients with a short
bowel; on behalf of the Small Bowel and Nutrition Committee of the British Society of
Gastroenterology. Published in Gut. Available at http://dx.doi.org/10.1136/gut.2006.
091108.
FUTURE DIRECTIONS

Four randomized placebo-controlled trials have been performed using growth hormone to stimulate mucosal growth for better absorption of nutrients.2830 In 3 studies
there was no significant increase in nutrient absorption, but 1 did show a small
improvement in nutrient absorption.31
GLP-2 has been shown to cause villus growth. Plasma levels of GLP-2 are low in
patients with jejunostomy.32 GLP-2 is given as subcutaneous injections, and a small
increase in nutrient absorption has been shown.33
Intestinal transplantations are possible in patients with intestinal failure, and more
than 1200 such surgeries have been performed worldwide. Intestinal transplant has
not yet been recommended as an alternative therapy for patients with intestinal failure
who have been safely maintained on long-term intravenous nutrition, which is partly
due to the excellent outcomes reported for long-term parenteral nutrition and the complications and challenges posed by intestinal transplant.34
REFERENCES

1. Hyland J. The basics of ostomies. Gastroenterol Nurs 2002;25(6):2414.

2. Bryant RA. Anatomy and physiology of the gastrointestinal tract. In: Colwell JC,
Goldberg MT, Carmel JE, editors. Fecal & urinary diversions: management
principles. St Louis (MO): Mosby; 2004. p. 3362.

e549

e550

Gondal & Trivedi

3. McCann E. Routine assessment of the patient with an ostomy. In: Milne C,

Corbett I, Dubuc D, editors. Wound, ostomy, and continence nursing secrets.
Philadelphia: Hanley and Belfus; 2003. p. 299305.
4. Tsao SK, Baker M, Nightingale JM. High-output stoma after small-bowel resections for Crohns disease. Nat Clin Pract Gastroenterol Hepatol 2005;2:6048.
5. Park JJ, Del Pino A, Orsay CP, et al. Stoma complications: the Cook County
Hospital experience. Dis Colon Rectum 1999;42(12):1575.
6. Porter JA, Salvati EP, Rubin RJ, et al. Complications of colostomies. Dis Colon
Rectum 1989;32(4):299303.
7. Pearl RK, Prasad LM, Orsay CP, et al. Early local complications from intestinal
stomas. Arch Surg 1985;120:11457.
8. Haq AI, Cook LJ. MRSA enteritis causing a high stoma output in the early postoperative phase after bowel surgery. Ann R Coll Surg Engl 2007;89(3):3038.
9. Rao VS, Sugunendran S, Issa E, et al. Metformin as a cause of high stomal
output. Colorectal Dis 2012;14(2):e77.
10. Baker ML, Williams RN, Nightingale JM. Causes and management of a highoutput stoma. Colorectal Dis 2011;13(2):1917.
11. Brown H, Randle J. Living with a stoma: a review of the literature. J Clin Nurs
2005;14(1):7481.
12. Simmons KL, Smith JA, Bobb KA, et al. Adjustment to colostomy: stoma acceptance, stoma care self-efficacy and interpersonal relationships. J Adv Nurs 2007;
60(6):62735.
13. Nightingale JM. Management of patients with a short bowel. World J Gastroenterol 2001;7(6):74151.
14. Windsor CW, Fejfar J, Woodward DA. Gastric secretion after massive small bowel
resection. Gut 1969;10(10):77986.
15. Jeejeebhoy KN. Short bowel syndrome: a nutritional and medical approach.
CMAJ 2002;166:1297302.
16. Kusunoki M, Shoji Y, Okamoto T, et al. Treatment of high output enterocutaneous fistulas with a somatostatin analogue and famotidine. Eur J Surg 1992;158(8):4435.
17. Parrish CR. The clinicians guide to short bowel syndrome. Pract Gastro 2005;
29(9):67. Available at: http://www.practicalgastro.com/getArticles.php?yr52005
&mon59&maxYr52013.
18. Newton CR. Effect of codeine phosphate, Lomotil and Isogel on ileostomy function. Gut 1978;19:37783, 94.
19. King RF, Norton T, Hill GL. A double-blind crossover study of the effect of loperamide hydrochloride and codeine phosphate on ileostomy output. Aust N Z J
Surg 1982;52:1214, 95.
20. Tytgat GN, Huibregtse K. Loperamide and ileostomy output-placebo-controlled
double-blind crossover study. Br Med J 1975;2:6678.
21. Spiliotis J, Tambasis E, Christopoulou A, et al. Sandostatin as hormonal temporary protective ileostomy. Hepatogastroenterology 2003;50(53):13679.
22. Sancho JJ, di Costanzo J, Nubiola P, et al. Randomized double-blind placebocontrolled trial of early octreotide in patients with postoperative enterocutaneous
fistula. Br J Surg 1995;82(5):63841.
23. Kusuhara K, Kusunoki M, Okamoto T, et al. Reduction of the effluent volume in
high-output ileostomy patients by a somatostatin analogue, SMS 201-995. Int J
Colorectal Dis 1992;7:2025.
24. McDoniel K, Taylor B, Huey W, et al. Use of clonidine to decrease intestinal fluid
losses in patients with high-output short-bowel syndrome. JPEN J Parenter
Enteral Nutr 2004;28(4):2658.

High-Output Ostomy

25. Goulston K, Harrison DD, Skyring AP. Effect of mineralocorticoids on the sodium/
potassium ratio of human ileostomy fluid. Lancet 1963;2:5413, 118.
26. Levitan R, Goulston K. Water and electrolyte content of human ileostomy fluid
after d-aldosterone administration. Gastroenterology 1967;52:5102.
27. Fukumoto S, Matsumoto T, Tanaka Y, et al. Renal magnesium wasting in a patient
with short bowel syndrome with magnesium deficiency: effect of 1 alphahydroxyvitamin D3 treatment. J Clin Endocrinol Metab 1987;65(6):13014.
28. Ellegard L, Bosaeus I, Nordgren S, et al. Low-dose recombinant human growth
hormone increases body weight and lean body mass in patients with short bowel
syndrome. Ann Surg 1997;225(1):8896.
29. Scolapio JS, Camilleri M, Fleming CR, et al. Effect of growth hormone, glutamine,
and diet on adaptation in short-bowel syndrome: a randomized, controlled study.
Gastroenterology 1997;113:107481.
30. Szkudlarek J, Jeppesen PB, Mortensen PB. Effect of high dose growth hormone
with glutamine and no change in diet on intestinal absorption in short bowel
patients: a randomised, double blind, crossover, placebo controlled study. Gut
2000;47(2):199205.
31. Seguy D, Vahedi K, Kapel N, et al. Low-dose growth hormone in adult home
parenteral nutrition-dependent short bowel syndrome patients: a positive study.
Gastroenterology 2003;124(2):293302.
32. Jeppesen PB, Hartmann B, Hansen BS, et al. Impaired meal stimulated
glucagon-like peptide 2 response in ileal resected short bowel patients with intestinal failure. Gut 1999;45(4):55963.
33. Jeppesen PB, Hartmann B, Thulesen J, et al. Glucagon-like peptide 2 improves
nutrient absorption and nutritional status in short-bowel patients with no colon.
Gastroenterology 2001;120(4):80615.
34. Woodward JM, Mayer D. Review: the unique challenge of small intestinal transplantation. Br J Hosp Med 1996;56(6):28590.

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