Whose problem is it anyway?
Not only is there variation in management strategies among subspecialties, but recommendations amongst societies within the same subspecialty differ, and thus make management perplexing.
Gastroenterology Guidelines
Several major gastroenterology societies have published guidelines on the management of diarrhea in patients with intestinal failure. The British Society of Gastroenterology (BSG) published guidelines on the management of SBS in 2006 and recommended the following first-line therapy for diarrhea-related complications: start loperamide at 2–8 mg thirty minutes prior to meals, taken up to 4 times per day, and the addition of codeine phosphate 30–60 mg thirty minutes before meals if output remains above goal on loperamide monotherapy. Cholestyramine may be added for those with 100 cm or less of resected terminal ileum to assist with bile-salt-induced diarrhea, though no specific dosage recommendations were reported. In regards to anti-secretory medications, the BSG recommends cimetidine (400 mg oral or IV 4 times per day), ranitidine (300 mg oral twice per day), or omeprazole (40 mg oral once per day or IV twice per day) to reduce jejunostomy output particularly in patients with greater than 2 L of output per day [15,34]. If diarrhea or enterostomy output continues to remain above goal, the guidelines suggest initiating octreotide and/or growth factors (although dosing and duration of therapy is not discussed in detail), and considering evaluation for intestinal transplant once the patient develops complications related to long-term TPN.
The American Gastroenterology Association (AGA) published guidelines and a position statement in 2003 for the management of high-gastric output and fluid losses. For postoperative patients, the AGA recommends the use of PPIs and H2RAs for the first 6 months following bowel resection when hyper-gastrinemia most commonly occurs. The guidelines do not specify which PPI or H2RA is preferred or recommended dosages. For long-term management of diarrhea or excess fluid losses, the guidelines suggest using loperamide or diphenoxylate (4-16 mg per day) first, followed by codeine sulfate 15–60 mg two to three times per day or opium tincture (dosages not specified). The use of octreotide (100 mcg SQ 3 times per day, 30 minutes prior to meals) is recommended only as a last resort if IVF requirements are greater than 3 L per day [8].
Surgical Guidelines
The Cleveland Clinic published institutional guidelines for the management of intestinal failure in 2010 with updated recommendations in 2016. Dietary recommendations include the liberal use of salt, sipping on 1–2 L of ORS between meals, and a slow reintroduction of soluble fiber from foods and/or supplements as tolerated. The guidelines also suggest considering placement of a nasogastric feeding tube or percutaneous gastrostomy tube (PEG) for continuous enteral feeding in addition to oral intake to enhance nutrient absorption [35]. If dietary manipulation is inadequate and medical therapy is required, the following medications are recommended in no particular order: loperamide 4 times per day (maximum dosage of 16 mg), diphenoxylate-atropine 4 times per day (maximum dosage of 20 mg per day), codeine 4 times per day (maximum dosage 240 mg per day), paregoric 5 mL (containing 2 mg of anhydrous morphine) 4 times per day, and opium tincture 0.5 mL (10 mg/mL) 4 times per day. H2RAs and PPIs are recommended for postoperative high-output states, although no dosage recommendations or routes of administration were discussed.
Nutrition Guidelines
Villafranca et al published a protocol for the management of high-output stomas in 2015 that was shown to be effective in reducing high-enterostomy output. The protocol recommended initial treatment with loperamide 2 mg orally up to 4 times per day. If enterostomy output did not improve, the protocol recommended increasing loperamide to 4 mg four times per day, adding omeprazole 20 mg orally or cholestyramine 4 g twice per day before lunch and dinner if fat malabsorption or steatorrhea is suspected, and lastly the addition of codeine 15–60 mg up to 4 times per day and octreotide 200 mcg per day only if symptoms had not improved after 2 weeks [37].
The American Society for Parenteral and Enteral Nutrition (ASPEN) does not have published guidelines for the management of SBS. In 2016 however, the European Society for Clinical Nutrition and Metabolism (ESPEN) published guidelines on the management of chronic intestinal failure in adults. In patients with an intact colon, ESPEN strongly recommends a diet rich in complex carbohydrates and low in fat and using H2RAs or PPIs to treat hyper-gastrinemia within the first 6 months after intestinal resection particularly in those with greater than 2 L per day of fecal output. The ESPEN guidelines do not include whether to start a PPI or H2RA first, which particular drug in each class to try, or dosage recommendations but state that IV soluble formulations should be considered in those that do not seem to respond to tablets. ESPEN does not recommend the addition of soluble fiber to enhance intestinal absorption or probiotics and glutamine to aid in intestinal rehabilitation. For diarrhea and excessive fecal fluid, the guidelines recommend 4 mg of oral loperamide 30–60 minutes prior to meals, 3 to 4 times per day, as first-line treatment in comparison to codeine phosphate or opium tincture given the risks of dependence and sedation with the latter agents. They report, however, that dosages up to 12–24 mg at one time of loperamide are used in patients with terminal ileum resection and persistently high-output enterostomy [38].