Burch, J. (2008) Nutrition for people with stomas 2: an overview of dietary advice. Nursing Times; 104: 49, 26-27.
This two-part unit examines nutrition for people with stomas. Part 1 outlined the three types of stomas - colostomy, ileostomy and urostomy - and diet in general. This part focuses on post-operative and long-term dietary needs. It includes advice on diet related to enhanced recovery and specific to types of stoma.
Jennie Burch, BSc Nursing, Dip Adult Nursing, ENB 998, 980, 216, is enhanced recovery facilitator, St Mark’s Hospital, Harrow, Middlesex.
- Be able to identify the dietary needs of people with stomas in the post-operative period.
- Know how to explain this group’s dietary requirements following hospital discharge.
General dietary advice for people with stomas
In the long term, patients with stomas may eat and drink as before their stoma-forming surgery (Porrett, 2005).
This should be a balanced diet including a combination of food types. General useful advice may include chewing the food well, drinking at least eight cups of fluid daily and eating regularly. However, patients may find that certain foods adversely affect their stoma and may choose to avoid these. Occasionally food restriction, in terms of both quantity and type, is required.
It is possible to drink alcohol but this should be in moderation and it may affect stoma function. In people with colostomies or ileostomies, alcohol may lead to a looser faecal output. Those with urostomies may find they have an increase in urine output.
Enhanced recovery and diet
Length of postoperative hospital stay is decreasing for many surgical procedures as techniques improve. This is partly due to minimally invasive surgery, including laparoscopic surgery, but the principles can also be applied to open surgery. For example, 10 years ago the expected length of stay following bowel surgery was 14 days; this is now as low as four days if patients are on the enhanced recovery pathway and have had laparoscopic surgery.
Many elements of enhanced recovery are necessary to ensure patients are well enough to be discharged, including appropriate use of analgesia, mobilisation and diet. The only aspects examined here are related to diet, although this alone is not adequate to achieve an early and safe discharge home.
With enhanced recovery, patients receive a normal diet pre-operatively. They are also given nutritional supplements pre-operatively, throughout their hospital stay and perhaps for a period of time following discharge home. After surgery patients are actively encouraged to eat and drink as soon as they are awake.
Additionally, fluids are given parenterally in the post-operative period but stopped after 24 hours (Billyard et al, 2007). Practice may vary slightly in different hospitals.
In the immediate post-operative period, there is some debate about what diet is acceptable for patients with stomas. However, it would seem sensible to encourage oral fluids and chewing food well during this period. Patients should be encouraged to have food little and often and, if they experience nausea, then food intake should be reduced for a short period.
People with colostomies
In general, these patients can and should eat a ‘normal’ balanced diet with adequate fluids (about 1.5L per day) (Pearson, 2008) but there is little objective research on dietary habits after a colostomy. Some people with colostomies associate certain foods with problems such as flatus, faecal malodour or loose stool and may choose to consume these foods in moderation. A poor diet (for example, one lacking in fibre) can lead to constipation, which may be resolved by eating regular meals to try to promote regular stoma function. Constipation can also be caused by an inadequate fluid intake or may be the result of side-effects of drugs such as analgesics.
Dietary fibre is not digested in the small bowel and passes to the colon. It increases the faecal bulk and waste passes more quickly through the colon, leaving less time for water to be absorbed and making the faeces softer and thus easier to pass. This means it might be possible to prevent constipation by increasing fibre (Borwell, 2005), which is contained in foods such as wholemeal or granary bread, wholegrain cereals, fruit and vegetables. Fibre should be introduced slowly to the diet as it may increase flatus production and bloating. In addition to increasing fibre intake, fluid must also be increased (Pearson, 2008).
People with colostomies may also experience bouts of diarrhoea. This may be caused by infection, stress or side-effects of medication such as antibiotics. Food and drink - such as spicy or fried foods, alcohol and caffeine - may also cause diarrhoea. If food or drink is suspected as the cause, consuming this in smaller quantities may reduce symptoms (Pearson, 2008). Anti-diarrhoeal medication, such as loperamide, may be taken to slow bowel transit and thicken stool, following careful review to ensure there is no underlying problem. Stoma specialist nurses should investigate this.
People with colostomies have no voluntary control over when they pass flatus, which can be embarrassing (Williams, 2008b). Flatus is produced as part of the digestion process and from ingested air (Burch, 2008b). Swallowed air may be reduced by:
- Eating slowly;
- Chewing food;
- Avoiding talking while eating;
- Avoiding smoking;
- Avoiding chewing gum;
- Avoiding drinking with a straw;
- Avoiding fizzy drinks (Pearson, 2008).
Alcohol may be consumed, but excess may cause loose stool. It can also lead to dehydration and this may cause constipation, so moderation is recommended.
People with ileostomies
Most nutrients are absorbed in the upper small bowel, so patients with ileostomies can generally have a good diet without obvious problems.
Even though it is possible to live well without a colon (which is removed or not used in this group), these patients need to ensure adequate dietary fluids and sodium (salt). In the long term, they may not need to take additional salt if their diet includes some salty or processed foods (Pearson, 2008).
Around 6-8 weeks after the ileostomy is formed, function settles and generally people become more confident to experiment with food. Those with ileostomies often follow a low-fibre diet including white bread and pasta. However, they also need to eat fruit and vegetables, which should be chewed well to reduce the risk of blockages. Some people remove skins, seeds and pips.
Another option is to use tinned or well-cooked versions. Alcohol can cause looser stool and should be consumed in moderation.
A blockage can occur if foods are not well chewed. This is most likely in the post-operative period due to bowel oedema. People with newly formed ileostomies should therefore be advised to avoid foods such as nuts, raw vegetables, salad, peas, sweetcorn and mushrooms for the first six weeks post-operatively (Pearson, 2008). These foods can then be reintroduced to the diet in small, well-chewed portions.
If a blockage occurs, it may cause abdominal pain and bloating and the stoma may stop working. Stopping eating but continuing with fluids may pass the blockage. If this fails, hospital admission may be required for IV fluids.
People with ileostomies may also have a high faecal output, which is usually temporary. If the output exceeds 2L it may lead to dehydration, which can be indicated by a urine output of less than 1L daily (Nightingale and Woodward, 2006).
Short-term treatment may include IV saline. If output is continually high, due to extensive small bowel resection for example, then long-term use of an electrolyte solution containing sodium, glucose, sodium bicarbonate and water may be necessary. Salty foods and a low-fibre diet can also be useful, along with anti-diarrhoeal medication.
Some patients with a permanently high stomal output have a restricted oral fluid in addition to their daily electrolyte solution. It can also be useful to take anti-diarrhoeal medication 30-60 minutes before food for best efficacy, and to restrict oral fluid for 30-60 minutes before and after meals, to prevent medication and/or food from passing too quickly through the gastrointestinal tract.
People with urostomies
Urostomies do not affect absorption of fluid and nutrients, so these patients can maintain a normal balanced diet (Pearson, 2008).
However, people with urostomies can suffer from urinary infections, which may be prevented by drinking 2L of fluid daily (Fillingham, 1999). They may require more fluid during hot weather or exercise. Although alcohol can be drunk, it will increase urine output if consumed in large quantities, particularly pints of beer, cider or lager, and moderation should be exercised.
Anecdotally, cranberry juice, up to 250ml twice daily, can prevent urinary infection in this group (Busuttil, 1996). However, cranberry products are not recommended in people taking warfarin as they may cause an adverse reaction (Drug and Therapeutics Bulletin, 2005). Patients with diabetes should choose low-sugar versions.
In addition, certain foods such as oily fish, onions, garlic and some spices may change the urine odour. Beetroot may colour it pink or red if consumed in excess and this can cause alarm.
Although in theory it is possible for people with stomas to have a ‘normal’ diet, many factors can affect this.
For people with colostomies, the diet can remain relatively unchanged. However, there may be dietary problems associated with constipation or flatus. Those with ileostomies may have problems associated with food blockage or loose stool. Finally, people with urostomies may be more prone to urine infections, which dietary changes may prevent.
Patients should be advised to consult their stoma nurse if they notice any changes in stoma function.
Billyard, J. et al (2007) Implementing an enhanced recovery programme in a district general hospital. Gastrointestinal Nursing; 5: 9, 32-39.
Borwell, B. (2005) Dietary considerations following stoma surgery. In: Breckman, B. (ed) Stoma Care and Rehabilitation. London: Elsevier Churchill Livingstone.
Porrett, T. (2005) Questions commonly asked by the patient with a newly formed stoma. In: Porrett, T., McGrath, A. (eds) Stoma Care. London: Blackwell Publishing.
Williams, J. (2008b) Flatus, odour and the ostomist: coping strategies and interventions. British Journal of Nursing; 17: 2, S10-S14.