There are over 205 000 people in the UK living in the community with a stoma. There are potential issues with body image that are encountered when living with a stoma (Porrett, 2022). Other issues relate to learning to live with a stoma; for example, developing the practical skills necessary to care for one's stoma appliance (Jin et al, 2021). This is important as it is reported that 80% of people living with a stoma will develop some form of peristomal complication within the first couple of years (LeBlanc et al, 2019), which can negatively affect quality of life (Rolls et al, 2022). The physical care of the appliance and how to change it, is learnt in hospital; however, learning to adapt dietary intake takes longer as most people do not eat a full diet when they are discharged home. It is important for community nurses to consider diet and the stoma as this is often a complex situation in which patients want advice. Unfortunately, research is limited in the area and advice provided by healthcare professionals can be contradictory, especially for the care of high output stomas. This article explores the types of diet people with stomas should consider adopting, with the aim to increase understanding and standardisation of information provided.
Stomas
There are three main types of output stoma: a colostomy, ileostomy and urostomy. While the exact number of people living with a stoma in the UK remains unclear, it is estimated to be about 1 in 350 people (Hodges, 2022). The most common reasons for stoma formation are cancer such as rectal and bladder, as well as inflammatory bowel disease or imperforate anus in children.
A stoma is surgically formed when part of the bowel is brought to the surface of the abdominal wall through a small incision in the rectus muscle. When the stoma is formed, it is stitched in place with dissolvable sutures. After a few weeks, in most situations, the wounds will have healed between the abdominal wall and the bowel mucosa. As the stoma is formed of bowel, it is pink to red in colour with moist bowel mucosa. The shape of a stoma is usually round for people with an end stoma or oval shaped for loop stomas.
A colostomy is usually formed from the descending or sigmoid colon but can be formed from any part of the colon. It is important to note that a colostomy formed in a distal portion of the colon will pass faeces that are more formed than from proximal portions of the colon. In general, the output passed via a colostomy is flatus and formed faeces, the latter often once daily. Faeces are collected into a closed appliance that is replaced when dirty, usually once daily. As the distal portion of the colon is on the left side, most often a colostomy is formed in the left iliac fossa. A colostomy is ideally minimally raised above the abdominal wall by about 5 mm.
An ileostomy is usually formed from the distal portion of the ileum, called the terminal ileum, but can be formed from any part of the small bowel. The output from the small bowel is looser than the output from the colon and can be described as loose or porridge-like in consistency as well as flatus being passed. Faeces are passed throughout the day and night and are collected into a drainable appliance. Loose faeces are released from the drainable appliance via the opening which is often fastened with a Velcro type fastening, and often requires emptying 4–6 times a day and sometimes once at night as well. The volume of the faeces is usually 600–800 ml daily, depending on dietary intake (Nightingale, 2001). The ileostomy is commonly formed in the right iliac fossa and is ideally formed into a small spout of about 25 mm.
A urostomy is usually formed from a segment of ileum; thus, it can be termed an ileal conduit. The output from the urostomy is urine with a small amount of mucus that originates from the bowel mucosa used in the conduit. Urine is passed throughout the day and night and is collected into a drainable appliance. A urostomy appliance is fastened using a tap or bung. The fastening can also be attached overnight to a night or leg bag to enable a larger urine storage capacity. The urine needs to be drained from the appliance 4–6 times daily, depending on the intake. The urostomy is commonly positioned in the right iliac fossa and is ideally formed into a small spout of about 25 mm.
Gut function in health
It is important to consider the way in which the gut functions as it can indicate what changes might occur after stoma formation. After ingesting food and fluids through the mouth, where chewing with teeth and mixing with saliva occurs, digestion commences, and the food is swallowed into the stomach and digestion continues for several hours. Within the stomach, acids such as hydrochloride acid are added to reduce any bacterial load as well as to enable chemical breakdown of the ingested foods. Additional mechanical digestion occurs as the muscular walls of the stomach churn the stomach content. There are various mechanisms that can increase or delay the time that food and fluids remain in the stomach. Foods that leave the stomach quickly are clear fluids such as water, whereas fat-rich foods stay in the stomach for longer. As food leaves the stomach into the small bowel, most of the absorption of fluid and nutrients occurs within the duodenum, jejunum and ileum. Waste will then pass from the small bowel to the colon, where additional fluids and sodium are absorbed before the waste is passed from the body via the anus as faeces and flatus.
Diet
Diet is an important consideration for people with a stoma. Yet, there seems to be a lack of information about diet for patients with a stoma (Bowles et al, 2022). It is important to ensure a healthy, varied diet, that includes the important food groups (Burch et al, 2023). There are, however, slight dietary variations for each stoma type.
Postoperative diet
For all people with a newly formed stoma, it is important to gradually increase the diet and understand any restrictions (Porrett, 2022). This can be initiated by taking small, frequent meals in the first week or so (Fulham, 2004). Initially it is also important to chew food well in the immediate postoperative period. These measures enable the gut to accommodate the dietary intake after a short period of not eating and drinking. It is likely to cause discomfort if carbonated drinks are consumed, these are often better tolerated a few weeks after surgery.
It is also important to consider the reason that the stoma was formed and if the person was categorised as having malnutrition in the preoperative phase (Michońska et al, 2023). Malnutrition could be due to cancer cachexia or malabsorption due to inflammatory processes occurring due to Crohn's disease, for example. It is also common for many people, after any type of abdominal surgery, to encounter a degree of weight loss in the postoperative period, While this may be seen as a positive for obese patients, this may be problematic for already undernourished patients.
Increasing diet can occur gradually (Michońska et al 2023). Increasing variety as well as volume will depend upon how the person recovers as well as the type of stoma they had formed and the disease process that led to the stoma formation. Often, after a week or two, small amounts of well-chewed foods can be added to the diet, taking more caution for foods that might cause a problem, some of which are detailed below.
Colostomy
A person with a colostomy often does not need to change their diet in any meaningful way after their stoma formation. Flatus can be reported as problematic, when passed anally there is control but this is not possible with a colostomy, with flatus passed without awareness. Foods that increase flatus production include beans and pulses, as well as carbonated drinks, smoking and vaping (Michońska et al 2023). High fibre foods can be avoided if flatus is a problem, or alternatively, not eaten when flatus might be a bother.
Another issue that can occur for a person with a colostomy is constipation. If a person was prone to constipation prior to the stoma formation, it is likely to continue with the stoma unless circumstances change. Constipation can often be prevented using a few simple methods: diet, fluids and exercises. For example, diet needs to include adequate amounts of fibre such as from fruits and vegetables (Michońska et al 2023). Consumed fluids need to be adequate; for example, 1500–2000 mls daily, or more if there is excessive sweating such as during hot weather or exercise sessions. Finally, movement is important, such as walking daily. Alcohol can be taken within recommen-ded limits.
Ileostomy
A person with an ileostomy is more likely to need to alter their dietary intake than a person with a colostomy or urostomy (de Olieira et al, 2018). Although dietary changes are not needed by everyone, it is common to alter fibre intake to manage loose stool (Mitchell et al, 2021). One way of thickening faecal consistency with diet, is to increase the intake of processed carbohydrates such as white bread and reduce the intake of wholemeal and wholewheat versions of bread and pasta, for example (Bridges et al, 2019).
There is a risk of the smaller diameter of the ileum blocking with food boluses, particularly in the first 3 months after the ileostomy is formed and the bowel is still oedematous. To reduce the risk of a blockage it is advisable to chew food well (Michońska et al 2023) and to avoid high fibre foods for the first few months after the ileostomy is formed. Foods that have anecdotally been reported to cause a food bolus blockage include sweetcorn, mushrooms, popcorn and tough meats (Michońska et al, 2023). These foods can be consumed safely, starting with small amounts in the first few months and increasing gradually thereafter, but not in excess.
As there is slightly less sodium absorption, which occurs in health in the colon, a person with an ileostomy will frequently need to take a little extra salt each day. Additional salt intake is particularly important if the faecal output is over 1 litre per day or there is sweating due to exercise. The addition of salt may not be necessary for a person who already consumes a diet high in processed foods.
It is also important to ensure adequate fluids are consumed, to prevent dehydration. In general, a person with an ileostomy needs to drink 1500–2000 mls of fluid each day. Alcohol can be taken, with care not to become dehydrated.
Urostomy
Apart from in the first few weeks it is not usually an issue to consume any type of diet that was taken prior to the urostomy formation. The shortening of the urinary tract means that an infection would relate to kidneys, compared to the bladder. Thus, care is needed to ensure that adequate fluids are taken, ideally about 2000 mls daily. Alcohol can be taken, but care is needed to ensure that the increased urine output is emptied in a timely manner to prevent the urostomy appliance from overfilling.
High output ileostomy
A high output ileostomy is an uncommon occurrence but can be difficult to manage and risks serious repercussions such as an acute kidney injury (Bridges et al, 2019). An output of more than 1500 mls daily from the ileostomy is considered high (Arenas Villafranca et al, 2015) and can be due to inflammation within the small bowel, which might occur with Crohn's disease, an infection, stress or multiple small bowel resections. A prolonged high output stoma can result in weight loss and electrolyte imbalance; commonly seen as low levels of sodium, potassium and magnesium when testing blood. There is more risk of peristomal skin damage with a high output stoma. A prolonged high output stoma can result in weight loss and electrolyte imbalance, commonly seen as low levels of sodium, potassium and magnesium when testing blood. There is greater risk of peristomal skin damage with a high output stoma; high-output ileostomies carry an increased risk of appliance leakage. This is due to the increased liquid consistency of the faecal fluid, along with its higher concentration of digestive enzymes, making it prone to seeping under the appliance flange.
Diet can be one way to manage a high output stoma, often in conjunction with medication, to slow the bowel transit such as loperamide. Ways to thicken the bowel motion that have previously been described should be encouraged. In addition to reducing the speed at which the food and waste travel along the bowel, it can be useful to separate fluids and foods. This can be achieved by encouraging people not to drink during or within an hour of food. This enables the nutrients to be absorbed from the food before it is flushed from the body. Furthermore, avoidance of sorbitol can be beneficial as this can result in loose stool.
Electrolyte replacement can be managed with a fluid rehydration solution such as the St Mark's solution or the WHO solution (Mountford et al, 2013). In addition to replacing electrolytes, it can also be necessary to restrict other fluid intake to 1 litre over the day, if these fluids do not contain electrolytes (Medlin, 2012). A fluid restriction sounds counterintuitive to manage a high output stoma. A fluid restriction for a high output stoma can be explained to patients as necessary but complicated. The rationale for fluid restriction is, the first part of the bowel likes to maintain a certain salt concentration, so if people drink fluids such as water or tea which contains no salt, then the concentration of salt in the duodenum will weaken. To restore the concentration level, the body will remove salt from other places into the duodenum with a little fluid. Usually in health this extra fluid and sodium will be reabsorbed later within the gut, but when there is a high output stoma, the fluid is passed from the stoma before this process can occur. Thus, drinking water, tea, coffee, for example, will reduce salt and fluid levels which can cause dehydration.
Conclusion
Community nurses are integral in caring for people living in the community, which includes people living with a stoma. Many people do not feel confident in caring for all aspects of their stoma when leaving hospital and one such area is knowing what they can and cannot eat. With increased knowledge the community nurse should feel empowered to provide knowledge about dietary intake for people with the three main types of output stoma.