High Output Stoma Complicating Nutritional Therapy in Severely Malnourished Patient With Right Ascending Colon Cancer: A Case Report

OBJECTIVES: Ascending colon cancer makes up of 27% colorectal cancers, and its incidence has continuously increased. Malnutrition is common in cancer patients, posing as a risk of poor surgical outcome. High output stoma (HOS) is a commonly encountered complication with an incidence of 23%. Not only causes fluid and electrolyte imbalance, it also deteriorates patient's nutritional status, forming a vicious cycle of malnutrition. METHODS: A 43-year-old malnourished female with ascending colon cancer presented to the emergency department with signs of bowel obstruction. The patient underwent tumor resection and ileocolostomy surgery. Starting from the third postoperative day, ileostomy effluent drastically increased to 2700 mL/day. Simultaneously, severe hyponatremia, severe hypokalemia, and hypomagnesemia were observed. Intravenous electrolyte correction and antimotility drug were given. It was decided that oral nutrition intake remained to be given. Oral hypotonic fluid intake was limited to 1000 mL/day. Malignancy-related retroperitoneal abscess further complicated patient's condition. RESULTS: Hypersecretory phase was expected in first days after ileostomy surgery. However, HOS, especially with output of more than 2000 mL/day, could cause fluid and electrolyte imbalance. Moreover, HOS could cause malnutrition due to reduced nutrient absorption. Risk factors of HOS identified in this case were prokinetic medication use and unresolved retroperitoneal abscess causing intraabdominal inflammation. Increment of food intake was also observed from prior anorexic period, specifically fruits high in insoluble fiber were consumed. Fruit pulp was found in the stoma effluent, raising concern of reduced bowel absorption capacity. High output stoma was resolved by abscess drainage, discontinuation of prokinetic agent, and administration of antimotility agent. Hyponatremia and hypomagnesemia improved with correction, whereas hypokalemia needed longer time to be resolved. Oral nutrition was maintained and increased gradually to prevent further malnutrition, while stoma production was monitored strictly. CONCLUSIONS: This case report showed that strict evaluation on stoma production and management of HOS in malnourished cancer patients must be done promptly, preventing further deterioration. FUNDING SOURCES: None.