[Enteral nutrition in patients with ileostomies and jejunostomies]

Jejuno- and ileostomy are common surgical procedures. Due to shortening of effective bowel length intestinal failure, or short bowel syndrome develops. Degree of intestinal failure depends upon 1. resection length, 2. resection location, 3. function of the bowel remnant, stomach, pancreas and liver, 4. adaptive capabilities of the bowel remnant and 5. the disease that was cause of the surgery. In majority of these patients adequate nutrition can be achieved using enteral nutrition. Water and mineral absorption differs between jejunum and ileum. Jejunal mucosa is permeable to sodium and water, causing jejunal content to be isoosmolar to plasma. When sodium concentration in jejunal content is less than 90 mmol/l secretion of sodium into the lumen occurs. Ileal sodium absorption takes place against concentration gradient. Potassium concentration of jejuno- and ileostomy effluent is fairly constant at about 15 mmol/l. Main therapeutic problem is water and mineral loss. In jejunostomy patients hyponatremia is a major concern. Urinary sodium concentration of less than 5 mmol/l is a sign of sodium deficiency. This group of patients should have daily urinary output of more than 800 ml, and urinary sodium concentration of more than 20 mmol/l. Another important problem is malnutrition. Weight changes, albumin and trasferin are important follow-up parameters. Often neglected problem is large stomal effluent volume, that can incapacitate patient for the usual life. All these problems can be prevented by the adequate nutritional support. Oral' fluids should have minimal sodium concentration of 90 mmol/l. Intake of sodium poor fluids should be restricted. If plasma or urinary sodium are low intravenous sodium supplementation is warranted. Magnesium and zinc should be monitored and supplemented. Addition of vitamin D can improve their absorption. Vitamins B12 and K must be given parenteral, because their resorption is severely impaired. Patient should eat usual food rich in carbohydrates and proteins, but exact menu must be individualized, and reached by trial and error process. Fat absorption is proportional to fat intake. Fat does not increase stomal effluent, therefore there is no reason to restrict intake. In order to reduce stomal effluent volume and bowel motility H2 blockers, proton pump inhibitors and antidiarrhoeal drugs (codeine or loperamide) should be used.