The Importance of Ostomy Hydration
Proper hydration can be a major quality of life determinant in people with ileostomies, however achieving it requires a deeper understanding of how nutrients are absorbed by a body affected by a colectomy or small bowel resection.
This topic was at the core of “Ostomy Hydration With Dr. Raman,” a virtual presentation by Calgary-based Dr. Maitreyi Raman during the June meeting of the Calgary Ostomy Society.
Dr. Raman, a gastroenterologist and physician nutrition specialist, is currently an associate professor at the University of Calgary who specializes in examining the correlation between malnourishment and inflammatory bowel disease.
“Living with an ostomy can really raise several nutrition and hydration-related concerns,” she says.
“And the degree of symptoms that you may experience usually revolves around the length of bowel that has been removed.”
Dr. Raman began by noting that most people with an ileostomy have had their colon removed, however, those with small bowel removal face additional challenges when it comes to staying hydrated.
“The degree of small bowel that is removed is typically the major determinant of how much hydration impacts you,” she says.
This can be attributed to electrolyte disturbances, as the small bowel is where nutrients are absorbed.
“Not having a large intestine doesn’t mean you will be malnourished, because most of the nutrients are in fact absorbed in the small bowel,” says Dr. Raman.
“So if you lose your large intestine you might have problems with hydration, but you shouldn’t have any problems with absorption of nutrients.”
The large intestine, she explains, is an important organ to help absorb fluids, meaning those who still have their small bowel but who have undergone a colectomy are also at risk of facing hydration challenges.
“Regardless of the length of small bowel, many patients with ostomies, in general, complain of decreased energy, increased fatigue, and they may complain of major quality of life challenges,” she says.
Kidney stones, a topic that Dr. Raman briefly touched on during the presentation, can also be caused by chronic dehydration.
According to Dr. Raman, these negative physiological outcomes can happen when stool output exceeds two litres a day, the threshold for being considered “high output.”
This level of output can be caused by medical determinants like the colon being absent, inflammation, or the loss of the ileocecal valve that connects the small bowel to the large bowel.
“If you lose all of these factors, then these regulatory mechanisms are lost and it becomes quite easy at times to exceed that two litre threshold.”
However, a high output can also be caused by dietary factors, such as drinking sugary or caffeinated beverages, consuming insoluble fibre, combining solid foods and liquids together, or eating large meals.
One cause of output aggravation that might be unknown to people living with an ostomy is the consumption of hypotonic water, or regular water that hasn’t had any additional nutrients added to it. Dr. Raman gave an example of a patient of hers who was suffering from persistent thirst despite consuming over three litres of water a day.
“So when you drink water, in order for your bowel to be able to absorb water it needs to have the perfect balance of salts and sugars, but water has none of that,” says Dr. Raman.
The key to staying hydrated, she says, is to drink an oral rehydrating solution, or ORS.
“When we talk about oral rehydrating solution, we talk about a specific dose of sodium, and that ideal sodium dose, and I want you to remember this number, is 75 millimoles per litre,” she says.
This level can be translated into 2.6 grams per litre of sodium chloride. Other key components of ORS include glucose that’s anhydrous, or doesn’t contain water, as well as potassium and citrate.
The “gold standard” recipe for ORS outlined by the World Health Organization (WHO) was shown in the presentation along with some alternatives, with the simplest recipe involving simply adding salt to Gatorade G2, as regular Gatorade has too much sugar.
Other pre-made hydrating solutions like Hydralyte, says Dr. Raman, fall short of reaching the optimal sodium level.
As a word of caution, Dr. Raman noted that hydration and nutrition plans should be tailored to the individual. People with active Crohn’s, for instance, might experience adverse effects from Gatorade G2.
Once an individual has found an ORS that works for them, this should then become their dominant source of daily hydration.
“The important thing is that most of your fluid, so greater than two-thirds of your fluid should come from an oral rehydrating solution, and you should use this divided fairly equally throughout the day,” says Dr. Raman.
She also notes that consuming ORS should be centred around periods of physical activity, and individuals with an ostomy who are new to ORS might have to take a multivitamin or mineral supplement until their ostomy output is less than one litre a day.
Other factors that can improve ostomy output include eating more soluble fibre, choosing lactose-free products, separating liquids from solids by 30 minutes, limiting caffeine intake, and having multiple meals throughout the day instead of three big meals.
Dr. Raman concluded the hour-long presentation by pointing out that dehydration can also affect mood and have an impact on mental health. This, she says, is yet another reason why optimizing hydration is a critical piece of managing the quality of life in people with ileostomies.
Presentation by Dr. Maitreyi Raman. Article by Jonathan Crane, co-editor for Calgary Ostomy Society. June 2021.
Connect with Dr. Maitreyi Raman via LinkedIn