5 Things All RDs Should Know Regarding Ileostomies and Nutrition

Ileostomies are quite common in both short and long-term care.  They are performed for a wide variety of reasons, but they often present very similar challenges to the overall health of the patient. Due to their impact on nutrient availability and the functional capacity of the GI as a whole, many patients experience high levels of gut wall-derived inflammation, hyperglycemia, dysbiosis, and micronutrient deficiencies.

These conditions can be mitigated with several key nutrition-related interventions.

First, start enteral nutrition support as soon as possible. The most recent investigations clearly illustrate how essential it is to feed the GI and microbiota real food in order to maintain intestinal wall integrity and tight gap junctions. For each hour that there is a delay in transitioning the patient from parenteral to enteral nutrition support, there is a loss of at least some protective mucosal layer and a decline in the armies of microbes that support it (1).

Next, ileostomy patients frequently develop associated infections and even more often experience major disturbances in their unique microbiome-ecosystems.  Many of these aberrations cause long term complications that range from inflammation to diarrhea. Clostridium difficile is a common pathogen that finds dominance over beneficial bacteria in ileostomy protocols requiring antibiotics and longer hospital stays.  It is very important for RDs and MDs to use probiotics prophylactically in an effort to maintain good gut flora levels.  While a range of bifidobacter and lactobacilli strains are helpful, lactobacilli reuteri in particular would be highly recommended for improving the patient’s immune response and for outcompeting potential pathogens (2).

An inability to effectively metabolize high carbohydrate densities, resulting in ileostomy patients with hyperglycemia is very common.  It is important to avoid the use of enteral formulas with simple sugars and significant refined carbohydrate contents.  Starches from vegetables and legumes, with lower glycemic indexes than carbohydrates from maltodextrin, corn syrup solids, and modified food starch, are advantageous for better glycemic control.  In addition, avoiding bran and the non-fermentable cellulose are also wise in supporting the recovery of the intestinal environment (3).

Surprising to many RDs is the susceptibility of ileostomy patients to metabolic acidosis. An inability to effectively absorb and/or metabolize key nutrients that offer support to the human bicarbonate ion generating system, required for maintaining optimal blood/tissue pH of 7.39, places a unique imperative on attention to the PRAL equation of the patient’s diet.  The Potential Renal Acid Load (PRAL) of any meal or enteral formula consists of balancing those acid contributors (protein/amino acids, sulfur, phosphorous) with those that contribute alkali (potassium, calcium, magnesium).  Recent research has shown that the absorption of these alkali contributors is often compromised in ileostomy patients, resulting in metabolic acidosis (4).  It is advised to use formulas that not only contain the RDAs or DRIs of these micronutrients but to also choose those protein sources that are effectively have less of a PRAL score.  This means that casein and milk protein concentrates are poorer choices while whey or brown rice proteins are better choices.

Lastly, in addition to several other micronutrients that patients often develop deficiencies of, zinc and copper deficiencies are the most common in ileostomy patients.  Checking serum zinc and copper levels weekly is advised starting before and/or soon after surgery.  Patients should be near the 50^th percentile or higher for each and supplementation should be considered to prevent those symptoms/conditions associated with deficiencies (5).

~ John Bagnulo MPH, PhD.

RESOURCES:

1. Ralls MW, Demehri FR, Feng Y, Woods Ignatoski KM, Teitelbaum DH. Enteral Nutrient Deprivation in Patients Leads to a Loss of Intestinal Epithelial Barrier Function. Surgery. 2015;157(4):732-742. doi:10.1016/j.surg.2014.12.004.

2. Valeur N, Engel P, Carbajal N, Connolly E, Ladefoged K. Colonization and Immunomodulation by Lactobacillus reuteri ATCC 55730 in the Human Gastrointestinal Tract. Applied and Environmental Microbiology. 2004;70(2):1176-1181. doi:10.1128/AEM.70.2.1176-1181.2004.

3. Edwards CH, Grundy MM, Grassby T, et al. Manipulation of starch bioaccessibility in wheat endosperm to regulate starch digestion, postprandial glycemia, insulinemia, and gut hormone responses: a randomized controlled trial in healthy ileostomy participants. The American Journal of Clinical Nutrition. 2015;102(4):791-800. doi:10.3945/ajcn.114.106203.

4. Ławiński M, Haraszczuk D, Gradowska A, Kostro JZ, Bzikowska A, Sobocki J. Strategies for early metabolic disturbances in patients with an end jejunostomy or end ileostomy. Experience from a specialized Home Parenteral Nutrition (HPN) center. Przegla̜d Gastroenterologiczny. 2017;12(2):111-117. doi:10.5114/pg.2016.58599.

5. Balay KS, Hawthorne KM, Hicks PD, Chen Z, Griffin IJ, Abrams SA. Low Zinc Status and Absorption Exist in Infants with Jejunostomies or Ileostomies Which Persists after Intestinal Repair. Nutrients. 2012;4(9):1273-1281. doi:10.3390/nu4091273.