Tag Archive for: output consistency

Maintaining Nutrition and Hydration in the Management of Short Bowel Syndrome

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Part II of a Two-Part Series featuring Emily Rubin MPH, RD, LDN, Thomas Jefferson University Hospital

Earlier this year, I shared the first part of this two-part series on maintaining nutrition and hydration in people living with short bowel syndrome (SBS) and ostomies (e.g., ileostomies or jejunostomies). In Part I, I talked about managing “Output Consistency” – including thickening or thinning out stools, as well as managing stool acidity – with a focus on diet and nutrition. This article addresses hydration considerations, including signs and symptoms of dehydration in people with SBS and rehydration strategies.

Both articles reflect my own clinical experiences, including more than two decades at the Thomas Jefferson University Hospital in Philadelphia where I am the Director of Clinical Nutrition and Lead Clinical Dietitian for the Division of Gastroenterology and Hepatology. These articles are not intended as medical advice. Please contact your doctor if you are experiencing high output, symptoms of dehydration or any other health-related concerns.

As I mentioned in the first part of this series, SBS is a serious and chronic malabsorption disorder that occurs when parts of the intestine are removed surgically or due to injury. The remaining intestine may not be able to absorb enough nutrients from food and drink. When this happens, people with SBS may be at increased risk of malnutrition, dehydration, electrolyte disturbances and/or diarrhea (increased output). I believe that patient education is critical and I am dedicated to teaching my SBS patients about what to expect in terms of stool/ostomy output, along with the risks and symptoms of dehydration. I am proud to share my clinical experience in this article.

Click here to learn more about SBS.

MANAGING HYDRATION AND RECOGNIZING THE SIGNS OF DEHYDRATION

A 60-year-old male patient with an ileostomy and approximately 80 cm of remaining small intestine was experiencing increased stoma output (about 2.5 L/day), resulting in frequent watery stools. He reported, “When I drink large amounts of water, I feel fatigued, dizzy, and I have muscle cramps!”

Contributing Factors:

  • Experiencing High-Output Stoma: During my consultation with the patient, I explained that excess fluid loss from his stoma led to depletion of electrolytes (sodium, potassium, magnesium), which can cause some of the symptoms that he reported.
  • Drinking Hypotonic Fluids: I shared with the patient that drinking hypotonic fluids, including plain water, can actually worsen dehydration by increasing ostomy outputs and making fluid and electrolyte disturbances worse. Hypotonic fluids are less concentrated than that of the fluids in the body. In addition to water, these types of fluids include plain, unsweetened tea, black coffee and sugar-free sodas.
  • Diet Low in Complex Carbohydrates: When the patient said that he consumes simple sugars and high-fat foods, I told him that these food choices draw excess water into the bowel, increasing stool output and worsening dehydration. Concentrated sweets, such as candy, cookies and cakes, as well as sweetened beverages like soda, juice and lemonade are all examples of simple sugars.

Understanding Stoma Output Levels

For people living with an ostomy, including those with SBS, I believe that understanding normal output levels is important for managing health. Typically, an ileostomy (post-op) produces around ~750mL per day, although output can be 1200mL or more per day initially. A jejunostomy, on the other hand, can produce significantly more—up to 6 liters per day. In contrast, a colostomy produces between 200-600mL daily. I tell my patients that it is important for the body to make at least 1000-1200mL of urine each day to protect the kidneys.

A high-output stoma occurs when output exceeds ~2 liters per day. This can lead to dehydration and the loss of essential minerals like sodium and magnesium, which are critical for overall health. For people with SBS, high stool output can significantly increase the risk of sodium depletion, with potential losses reaching up to 2430 mg per liter of output. I tell my patients who are experiencing high stool output and symptoms of low sodium, such as unexplained weight loss and fatigue, to contact their doctor.

Restricting Intake of Hypotonic Fluids

When I see patients with SBS who are experiencing high-output stoma in my clinical practice, I advise them to restrict the intake of hypotonic fluids like water, tea, black coffee, and sugar-free sodas. These fluids pull sodium (salt) into the small bowel, and bring water along with it, leading to increased stool outputs. In people with SBS, this can exacerbate fluid and electrolyte imbalances due to the lack of absorptive surface area for both salt and water in the remaining bowel. Drinking more water can worsen the condition by creating a cycle of increased ostomy outputs, associated dehydration and thirst for more water. Continue reading for rehydration options included in this article.

Dietary Factors Contributing to Dehydration

Foods that are low in complex carbohydrates and high in sugar can draw water into the gastrointestinal tract. These, too, can worsen stool output and cause fluid and nutrient losses for people with SBS.  I have seen firsthand in my patients that choosing complex carbohydrates, like white rice, potatoes, pasta, bread and bananas can help manage stoma output and improve nutrient absorption. These carbohydrates are easier to digest and absorb compared to simple sugars.

RECOGNIZING THE SIGNS OF DEHYDRATION

Did you know there are relatively easy ways to track hydration levels?

Urine Color

I tell my patients that monitoring their urine color can be a relatively easy yet effective way to keep tabs on their hydration levels. If the urine is darker than a pale yellow, it might suggest that the body is holding onto water rather than getting rid of it properly. Clear or light, yellow-colored urine reflects hydration. Darker shades of urine could signify dehydration.

Other signs of dehydration include:

  • Rapid weight loss
  • Higher stool output than total fluid intake
  • Less-frequent urination
  • Fatigue
  • Lightheadedness/Dizziness when standing
  • Dry mouth
  • Thirst

I tell my patients to consult their doctor if stool output increases, urine output decreases and they notice signs of dehydration.

Water-Tracking Apps

I have encouraged many of my SBS patients to set hydration reminders or alarms on their mobile phones. I have also suggested trying out water-tracking applications (or “Apps”). There are some water-tracking Apps that offer gentle hydration-related nudges throughout the day. Some Apps can help set goals and hydration-tracking progress. There’s even an App that lets users grow a virtual plant by staying hydrated! Searching for “water tracker” in an “App” store on your mobile device, tablet or desktop computer should bring up several options.

REHYDRATION

Did you know that Oral Rehydration Solutions are different than Sports Drinks?

Oral Rehydration Solutions (ORS)

When my patients with SBS are experiencing high output stomas leading to dehydration, I often try to incorporate Oral Rehydration Solutions (ORS) into their rehydration plans. ORS have a specific combination of sodium, carbohydrate and water in a special ratio that can enhance fluid absorption across the small bowel wall, even when the patient is experiencing diarrhea. In many of my SBS patients, I’ve seen this tailored blend help the body absorb those electrolytes like a sponge. However, ORS can be difficult for some people, because of the salty taste. Sometimes people find it helpful to make ORS into ice cubes or popsicles. Sugar-free flavoring can also be added to help improve the taste of the ORS.

Patients have asked me why they can’t simply buy Sports Drinks – such as basic electrolyte drinks – to rehydrate themselves. While Sports Drinks do contain electrolytes like sodium and potassium, as well as sugar, they are not ideal for SBS patients for effective rehydration. For example, they often have too much sugar and not enough salt. It is the special ratio of sodium, carbohydrate and water that can help with fluid absorption across the small bowel wall.

You can make your own ORS at home. Download a free-of-charge ORS recipe book here:

https://shortbowelsyndrome.com/Content/pdf/Recipe_Book_DIGITAL.pdf

If you are living with or caring for someone with SBS, I hope that the information that I have shared in this two-part article series helps empower you to bring questions about nutrition and hydration to your healthcare team. Consistent communication is critically important, and I encourage you to bring any concerns to your doctor, nutritionist, dietitian or another member of your SBS healthcare team.

Sometimes it can be challenging to find a healthcare provider who treats rare GI conditions like SBS. To check if there is a medical provider with SBS experience in your local area, visit https://shortbowelsyndrome.com/find-a-provider.

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Emily Rubin MPH, RD, LDN is the Director of Clinical Dietetics, Clinical Dietitian for Division of Gastroenterology and Hepatology at Thomas Jefferson University Hospital in Philadelphia. In addition to her extensive clinical work, her expertise and insights in the areas of diet and nutrition have been featured in numerous online and broadcast media outlets.

 

 

This article was created by Takeda.

Editor’s Note: This educational article is from one of our digital sponsors, Takeda. Sponsor support along with donations from our readers like you help to maintain our website and the free trusted resources of UOAA, a 501(c)(3) nonprofit organization.

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Maintaining Nutrition and Hydration in the Management of Short Bowel Syndrome

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Part 1 of a Two-Part Series featuring Emily Rubin MPH, RD, LDN, Thomas Jefferson University Hospital

With over two decades of experience at the Thomas Jefferson University Hospital Division of Gastroenterology and Hepatology in Philadelphia, I am the Director of Clinical Nutrition and Lead Clinical Dietitian for the Division of Gastroenterology and Hepatology. In this role, and over the course of my career, I have provided comprehensive nutrition education and medical management to patients of all ages living with a wide range of gastrointestinal diseases, including short bowel syndrome (SBS).

SBS is a serious and chronic malabsorption disorder that occurs when parts of the intestine are removed surgically or due to injury. The remaining intestine may not be able to absorb enough nutrients from food and drink. When this happens, people with SBS may be at increased risk of malnutrition, dehydration, electrolyte disturbances and/or diarrhea (increased output). I am passionate about educating patients and their family care partners about the roles of nutrition and hydration in the management of gastrointestinal diseases like SBS, and proud to share my clinical experience.

To learn more about SBS, click here. To join the community and talk to others who are living with SBS, check out https://www.facebook.com/TakedaSBS/.

The Nutritionist’s/Dietitian’s Role in Multidisciplinary SBS Care

Managing SBS can be complex, but working with experienced health care providers to establish a set of management goals that are individualized to the distinct needs of the patient can be an important part of self-advocacy. Since nutrition and hydration goals are important parts of an SBS management plan, a nutritionist or dietitian will often be included in an SBS patient’s multidisciplinary health care team.

 

Here at the Thomas Jefferson University Hospital Division of Gastroenterology and Hepatology, we see patients for a variety of reasons. In this two-part series, I am going to share my own clinical experience on two topics that come up frequently with our patients who are living with SBS and ostomies (e.g., ileostomies or jejunostomies). This article will address “Output Consistency” – including thickening or thinning out stools, as well as managing stool acidity. The second article in this series will focus on “Hydration” – including common causes of dehydration in people with SBS, as well as rehydration tips, including Oral Rehydration Solutions (ORS). That article will post in the coming months.

Managing Output Consistency

I see a 35-year-old female patient with a history of Crohn’s disease who underwent her third intestinal resection, resulting in short bowel syndrome (SBS) and an ileostomy. Since the surgery, she has struggled with managing high stoma output and persistent diarrhea and weight loss of 10 pounds over the past four months. She states, “Every time I eat too much fat, it makes my diarrhea worse, but I need to gain weight, so I am not sure what to eat?”

Considerations:

  • Weight Loss: Patient requires a diet that promotes weight gain without increasing stool output.
  • Dietary Concerns: She noticed that consuming high-fat foods exacerbates her diarrhea and stoma output; she needs to gain weight but is uncertain about what foods to eat that won’t worsen her symptoms.
  • Fluid and Electrolyte Management: Maintaining hydration and electrolyte balance is crucial to prevent dehydration due to her high-output stoma.

I stress to my patients that diet therapy is key for getting proper nutrition and for managing symptoms like diarrhea, which is often the biggest challenge for my SBS patients. I typically start with these important diet factors for SBS output consistency: I educate my patients about how to include Fat, Carbohydrates/ Sugar, and Fiber in their diets.

FAT

Did you know that eating too much fat, including fried or creamed based foods, can make diarrhea and output worse and cause nutrient and fluid loss?

Fat provides important calories but is a hard nutrient to digest. Limiting fat intake is most important in my SBS patients who have a remaining colon, severe steatorrhea (poorly digesting and absorbing fats) and/or a history of kidney oxalate stones. In some cases, I advise them to limit their fat to less than 30% of their daily calories and spread fat intake evenly throughout the day to help their bodies digest it better. When it comes to preparing foods such as fried or creamy based foods, I tell them to incorporate small amounts of easily digestible fats such as medium-chain triglycerides (MCTs) found in coconut oil. I have seen that these are better absorbed in my SBS patients.

I also educate my patients about avoiding High Fat Foods, such as fatty meats like beef, lamb, pork, and skin-on chicken and poultry. Dairy foods like whole milk, soft cheese, ice cream, and butter contain lactose. Symptoms of lactose intolerance are often dose-dependent, and some of my SBS patients can tolerate some dairy products, especially if they are spread over the course of the day.

I recommend that my patients incorporate healthier fat choices, such as fatty fish: salmon, tuna, olive oil, avocado and nut butters.

CARBOHYDRATES / SUGAR

Did you know that drinking 100% fruit juice can increase stool output and dehydration?

When my patients eat concentrated sweets, including candy (e.g., jellybeans or gummy bears), cookies, cakes, and drink sweetened beverages (e.g., soda, juice, lemonade), they draw excess water into the bowel, increasing stool output and exacerbating dehydration. Instead, I tell them to choose complex carbohydrates, like white rice, potatoes, pasta, bread and bananas, to help manage stoma output and improve nutrient absorption. These carbohydrates are easier to digest and absorb compared to simple sugars. I have seen that reducing stool volume and minimizing fluid loss can help my SBS patients maintain better hydration and nutrient balance.

FIBER

Did you know that incorporating soluble fiber like psyllium husk and oatmeal in the diet may improve stool consistency?

Fiber is often a scary word for my SBS patients. Soluble fiber found in oats, barley, citrus fruits, carrots, sweet potatoes, ground flaxseed, and psyllium husk can help to slow gastric emptying, potentially improving diarrhea and stabilizing bowel movements. Fiber dissolves in water, forming a gel-like consistency, which helps slow digestion and manage diarrhea. I tell my patients to focus on soluble fiber to improve stool consistency, especially if a colon segment remains. I encourage a moderate intake of soluble fiber to be spread throughout the day to help my SBS patients manage stool output and enhance fluid retention.

Although insoluble fiber, found in whole wheat, brown rice, bran, cauliflower, broccoli and dark leafy greens, may help thicken stool consistency, it can lead to increased loss of minerals and fluids, exacerbating dehydration. I frequently advise my SBS patients to avoid it.

I often remind my patients that they should not prioritize fiber over meeting their basic nutrient needs, especially for patients with poor appetite or requiring weight gain.

 

Additional nutrition tips I often share with my SBS patients, include:

Small, Frequent Meals: Eating smaller meals throughout the day can help manage symptoms and improve nutrient absorption.

Avoidance of Certain Foods with A Dietitian: Some foods might exacerbate symptoms, so identifying and avoiding these can be beneficial. A dietitian can help identify nutrient dense foods to include in an SBS diet to best manage symptoms based on the length of the patient’s remaining bowel, to help maintain hydration and to create a personalized nutrition plan.

Consistent Communication with Health Care Providers: I can’t stress to my patients often enough that they should always inform their doctor or dietitian about any changes to their diet or hydration plan. The patient’s health care team can adjust the patient’s treatment plan as needed to ensure they’re getting the right balance of nutrients and fluids.

Although there is no “one-size-fits-all” diet for SBS, your own health care team will work with you to develop nutrition and hydration goals that are specific to your needs. Diet therapy focuses on controlled fluid intake, nutrient absorption, and maintaining electrolyte balance to manage high-output stomas effectively. Again, it is important to tell your doctor and dietitian about any significant changes to your diet and output and identify signs of dehydration. A key aspect of nutrition and hydration management in SBS is educating patients on balancing nutrients, fluids and electrolytes.

To learn more about managing your SBS, visit https://shortbowelsyndrome.com/sbs-management.

Watch for Part 2 of this two-part series “Maintaining Nutrition and Hydration in the Management of Short Bowel Syndrome (SBS)” in the coming months!

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Emily Rubin MPH, RD, LDN is the Director of Clinical Dietetics, Clinical Dietitian for Division of Gastroenterology and Hepatology at Thomas Jefferson University Hospital in Philadelphia. In addition to her extensive clinical work, her expertise and insights in the areas of diet and nutrition have been featured in numerous online and broadcast media outlets.

This article was created by Takeda.

Editor’s Note: This educational article is from one of our digital sponsors, Takeda. Sponsor support along with donations from our readers like you help to maintain our website and the free trusted resources of UOAA, a 501(c)(3) nonprofit organization.

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