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I am quite unfamiliar with ostomies as I haven't had much clinical exposure, so the presentation by Tracy gave a great introduction. However, I am wondering if ostomies are a reversible procedure. If so, is there a certain time frame? Complications? Recovery? MNT after the reverse procedure?

-Jessica Hansen

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When reading the material for this module I was fascinated by the fact that Low FODMAP diets are also recommended for patients who have had ileostomy to help prevent diarrhea.  I knew there was research into Low FODMAP diets and their beneficial use in patient’s with IBS and/or IBD but not so much post ileostomies.  I know many times in the hospital we like to recommend low fiber or low residue diets for patients with ileostomies but never have I heard of Low FODMAP diet used for this purpose before.  According to the article, “ Fiber and Ileostomies: Does it Help or Hurt?” low FODMAPs are found to increase thickness of waste products thereby aiding in helping to prevent dehydration.  Changing of liquid medications containing sugar alcohols is also beneficial in prevention of dehydration in these patients.   Low FODMAP diets are also generally lower in fiber.

Jennifer M. Ephraim

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I learned in the lecture about Roux-en-y's that patients who are on insulin before surgery most of the time can leave the hospital after surgery completely off insulin. I also learned in the lecture about J, S, and W pouches, they use a barium enema to confirm there are no leaks in the pouch before reconnecting the tissue. In addition to that, I didn't think about the fact that the pouch tissue now has to learn how to function in a new way once it is reconnected.
-Miranda Miller

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I don't have a ton of practice experience with ostomies yet, especially in the peds population. I specifically remember one patient during my internship who was getting an ileostomy to cure her UC symptoms and she was just so happy to be getting this procedure because she was finally going to be able to eat without experience pain and discomfort. She was nervous but so excited.  She had a LOT of questions about what she could and couldn't eat. It was a lot for her to take in so it was important to go slow, answer her questions as best I could, and validate her concerns. Fortunately, we had a handout that covered most of what she needed to know, but I feel much more prepared to answer these questions after this module.
-Libbi C

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In the ostomy lecture, she specifically mentions avoiding corn on the cob with an ostomy. Is this corn on the cob specifically or just corn in general, and if just corn on the cob, why? If corn in general, then should they also avoid green peas? Also, can you explain why skipping meals causes gas? I feel like I've experienced this myself when I go a long time without eating, I get very bloated and sometimes get really bad stomach pain!
-Libbi C

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I learned about the different kinds of ostomies, like the double barrel ostomy, loop ileostomy, and the different shapes that the intestine can be left in for an ileal pouch (S, W, J). I didn't realize before how many different kinds of ostomies there were!
-Libbi C

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Whipple: Procedure and Nutrition Implications

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Whipple: Procedure and Nutrition Implications

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I learned many things regarding GI surgeries from the resources in this module. The Whipple procedure was particularly new to me, and I will also include some of the associated nutrition implications. A pancreaticoduodenectomy is called a Whipple surgery, which includes the removal of the following: the distal half of the stomach, the duodenum, proximal jejunum, regional lymph nodes, the head of the pancreas, the common bile duct, and the gallbladder. I was initially quite surprised at how many anatomical structures need to be removed in this procedure, and it is evident that there would be significant changes in GI function going forward. Many steps are then taken in the reconstructing of the remaining organs and glands. The pancreas is attached to the jejunum. Attaching the hepatic duct to the jejunum allows for digestive enzymes and bile to be able to flow into the GI tract. Finally, the stomach is attached directly to the jejunum.

There are several GI-related nutrition implications, that include the following: Delayed gastric emptying can be treated with promotility agents, laxatives, and an epidural with fluid balance to promote GI transit. Low-fat, low-fiber, and liquid foods are recommended. Dumping Syndrome may occur due to undigested gastric contents that are dumped into the small bowel too quickly, which can cause further GI side effects such as nausea and abdominal cramping. Nutrition interventions include smaller, more frequent meals, avoiding fluids with meals, avoiding foods with added sugars, and laying down after eating to slow the transit of food from the stomach to the remaining intestines. Diabetes mellitus becomes a higher risk since part of the pancreas (which produces insulin) is removed in this procedure. It is important to regularly monitor blood glucose levels, and to administer insulin when necessary. Lactose intolerance may occur in the short-term, as the lactase enzyme may become insufficient during and briefly after the surgery. Pancreatic exocrine insufficiency occurs in about 1 in 4 patients, which can cause frequent fatty, frothy, loose stools due to malabsorption. PERT enzymes of 500-2500 PERT units/kg/meal may be needed to provide enough digestive enzymes at meals. Micronutrient malabsorption is common with several nutrients, including calcium, zinc, fat, iron, and fat-soluble vitamins. Close monitoring and appropriate supplementation should be provided.

Reference:
Schmotzer T. GI Surgeries: Whipple/Pancreatectomy. University of Wisconsin – Madison. 2019. Retrieved on November 5, 2021.

-Nicole Tellock

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In terms of the protein shakes, I know that whey isolate is the best protein to use, but are there other guidelines for what should go into the shake?  Should it just be water and the powder?  Are there other things to keep in mind when choosing the whey protein isolate in terms of additives (especially sugar and alternative sweeteners)? Thanks!  -Rebecca Boenig

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In terms of the protein shakes, I know that whey isolate is the best protein to use, but are there other guidelines for what should go into the shake?  Should it just be water and the powder?  Are there other things to keep in mind when choosing the whey protein isolate in terms of additives (especially sugar and alternative sweeteners)? Thanks!  -Rebecca Boenig

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For my ostomy patients with high outputs, I have found that reinforcing soluble fiber intake (rather than just recommending to increase fiber) tends to be more helpful. This is something that was mentioned in our lecture but also something I have seen improve high outputs in a clinical setting. I usually share this handout with patients, encouraging them to choose foods higher in soluble fiber. This handout was actually shared with me by our wound/ostomy RN, who also noticed an improvement in output with many patients we had educated on soluble fiber.

soluble-fibre.pdf (carleton.ca)

-Rachel C

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Many of the topics you have brought up are things I learned with the readings and videos as well. So I tried to pick something different:
I was enlightened to find out how severe gallstones can be and that around 10,000 people die each year from them. It is no surprise that most of those deaths come from the development of pancreatitis.
I guess I didn't realize how serious gallbladder surgery could be. I know it is a very common procedure.
Lastly, I didn't realize how much of a lack of scientific evidence there is for diet recommendations after gallbladder surgery.
-Kelly Petersen

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Hi everyone,
I am a little confused regarding SBS patients and oxalate intake. Should all patients be avoiding intake of high oxalate foods or just patients who experience issues with fat malabsorption?

-Rachel Comstock

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I have had some experience working with patients who intend to enter the bariatric surgery program, but their insurance requires 6 months of nutritional counseling. It was clear that some of these patients were only seeing a dietitian because their insurance required it, and they weren’t motivated to make behavior changes. These patients were ultimately not appropriate for surgery, because it requires a lot of behavior changes. I also noticed that a lot of patients had disordered eating patterns, such as emotional eating or binge eating. One thing I have learned is that these eating patterns need to be properly addressed before considering surgery, and therapists who specialize in eating disorders can be helpful with this. -Ellen Magnuson

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I have a question in regard to nutritional management of delayed gastric emptying that commonly occurs in patients who underwent a whipple. I saw in the lecture that chewing gum is considered safe and may help accelerate gastric emptying. This confused me and I wonder how this works. I would think that chewing gum would cause more air to be swallowed, creating gas and abdominal discomfort. -Ellen Magnuson

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I found the presentation on bariatric surgery interesting; it was helpful to hear about how the UW health program operates. One thing I learned was that one of the complications of a RNY is strictures. This typically occurs 3-6 weeks after surgery and occurs because the scars shrink and become too tight. It appears this complication is relatively rare; however, it is important to be aware of all potential complications prior to considering surgery. Other complications of a RNY include pouch leaks and bowel obstructions. -Ellen Magnuson

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Hi there,

Throughout my time in clinical practice, I have seen a lot of patients with short bowel syndrome. The biggest issues with SBS is malabsorption and dehydration. Something that I like to recommend is a medicine called Gattex which works to stimulate the growth of small intestinal villi. This increases absorption and could potentially keep patients from readmitting from dehydration and from malnutrition/weight loss that can occur from SBS.
-Annalee Althouse

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Hi everyone!

I work in a small hospital but we do have our fair share of GI surgeries. That being said, I was surprised to learn that GI fistulas can spontaneously close without surgical intervention. In fact, the rate of spontaneous closure among patients is ~20%. That is fascinating to me! I am constantly amazed at the ways our bodies work for us

-Rachel Comstock

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I didn't know there was a process for patients to go through prior to and after surgery. Such as meeting with the multidisciplinary team and also taking pre-op nutrition classes. I also learned about the four pre-op nutrition classes and thought that was interesting and can see how those classes can set patients to be successful post-op. Another topic I learned were the pre-op and post-op diets and the amount of time it takes to progress to solids. Enjoyed this topic very much!

-Naomi

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Hello everyone, the question I have is the following. For patients with high ileostomy output, besides the diet modifications what else can you recommend to improve output. Can psyllium fiber (Metamucil) be helpful to bulk up the stool and decrease output? I once had a patient with 4-5 L output and diet modifications were not enough to help improve. Thank you!!

Samantha Sanchez

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Hi everyone! What an interesting module. I have no experience in working with bariatric surgery population, so I knew things here and there such as liquid diet pre-op, separating liquids and solids post-op and taking multiple vitamins/minerals daily d/t decreased absorption, BUT I had no idea that protein shakes are required in the first year after surgery! It makes sense to choose whey protein powder as it is best absorbed with is absorption rate ~10g per hour and to break this up into multiple meals/snacks vs taking it all at once to maximize absorption (this method is also utilized for athletes!). Any type of bariatric surgery requires commitment. -Agnes Kim

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Hi everyone! What an interesting module. I have no experience in working with bariatric surgery population, so I knew things here and there such as liquid diet pre-op, separating liquids and solids post-op and taking multiple vitamins/minerals daily d/t decreased absorption, BUT I had no idea that protein shakes are required in the first year after surgery! It makes sense to choose whey protein powder as it is best absorbed with is absorption rate ~10g per hour and to break this up into multiple meals/snacks vs taking it all at once to maximize absorption (this method is also utilized for athletes!). Any type of bariatric surgery requires commitment. -Agnes Kim

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Hi everyone! I don't work with bariatric surgery patients often. Prior to this module, I did not know that roux en y gastric bypass alters hunger hormones. I recently had a patient with a history of lap band then sleeve then RNY that is being evaluated to be a kidney donor who's currently taking phentermine for an appetite suppressant. On brief review, there's some studies showing appetite suppressants helping prevent weight regain post RNY. I'd love to hear if anyone has experience with this! --Ashley Peña Elsbernd

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I don't work with these patients often but the few times I have, I remember thinking the output patients have with an ileostomy is not consistent between patients. My best advice - each patient is different and some may experience output <1L and others >2L so be open minded and prepared for all volumes along with recommendations for each patient- B.Grenda. 

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I don't work with these patients often but the few times I have, I remember thinking the output patients have with an ileostomy is not consistent between patients. My best advice - each patient is different and some may experience output <1L and others >2L so be open minded and prepared for all volumes along with recommendations for each patient- B.Grenda. 

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It is recommended to look for pill absorption with those that have an ileostomy. Why wouldn't you automatically change medication form to liquid or crushed to prevent possible absorption issues?

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It is recommended to look for pill absorption with those that have an ileostomy. Why wouldn't you automatically change medication form to liquid or crushed to prevent possible absorption issues?

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Brandee Grenda

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What I found most interesting was that there is really no difference in outcomes when considering EN verses PN post a whipple. They always stress if the bowel works to use it but it appears that it may not be the case in these patients. I remember working with a MD that performed several Whipples and shake and bakes and I had a discussion with him requesting he place a J-tube for enteral nutrition verses starting PN right away. He agreed to do it but now I know why he was hesitant. 

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What I found most interesting was that there is really no difference in outcomes when considering EN verses PN post a whipple. They always stress if the bowel works to use it but it appears that it may not be the case in these patients. I remember working with a MD that performed several Whipples and shake and bakes and I had a discussion with him requesting he place a J-tube for enteral nutrition verses starting PN right away. He agreed to do it but now I know why he was hesitant. 

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Brandee Grenda

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Whipple surgery and pylorus-sparing procedure  

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Whipple surgery and pylorus-sparing procedure  

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In this module, I was fascinated to learn more about the Whipple procedure as I previously did not fully understand the complexity of the surgery. It’s amazing to me the number of resections and subsequent reconstructions that can be completed in one procedure. I found it interesting that the pylorus-sparing version of the surgery is more commonly done in Europe but not in the United States despite comparable long-term survival rates. As more data becomes available specific to outcomes associated with delayed gastric emptying and other postoperative complications, I’ll be curious to see if the procedure becomes more popular in the United States. -Sarah Luzinski

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We recently had a pt that required his bile to be reinfused along with TF. We had never had a pt requiring this process before (at least in the 13 years I've been on staff) so I knew it would be important to provide education and support to the nursing staff. My tidbit of advice is that when your hospital/unit/clinic/etc is faced with a new or unfamiliar process that relates to nutrition, it is important to make sure that you understand the process and then help other involved staff understand so that the pt is getting the care they require. Sometimes it is not enough to just include the information in your notes and in orders. Working with nursing leadership to explain the process and importance of it, touching base with the RNs assigned to the pt, going into the pt's room to see that it's being done and being done properly, reminding folks at rounds and/or huddles, etc. When this pt arrived at our facility I right away spoke with the House Supervisor and RN assigned to pt to make sure they understood the process which consisted of collecting the bile over the course of the shift and then reinfusing it just like you would infuse a water flush via the pump (this required a dual port feeding tube). I checked in with nursing staff daily  (especially if it was a different RN than the previous day) to ask how the pt was doing, how much bile output was being collected, and asking them to describe the process of reinfusing it to me so that I could be certain they understood. We eventually ended up being able to pull the drain on this pt due to output decreasing and they were able to start eating and eventually ate enough to transition off TF. I guess this tidbit isn't directly related to GI surgeries, but is hopefully still helpful!!
-Ashley Massart

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I wanted to share a bit of information that I had actually learned recently. I started covering our transplant and GI surgery floors in June so I have learned a TON during this time (& also a ton thanks to this class).

Recently I had a patient that got into a MVC and had a lot of abdominal surgeries. They ended up developing a high output ECF - normally I do not see these patients because frequently they are on TPN for life depending on where their fistula is and if they can get their output under control. Well, this patient was on TPN for a long time and then was able to come off of it and was put on a oral diet - which meant I would follow her now during her hospitalization.

I knew nothing really about ECF, the diet or how to aid in controlling output. Through this I learned that if the ECF is in the colon (where hers was) you could actually treat it similarly to if they had an ileostomy! Their body digests the food the same way, but it would come out of their fistula into a pouch (similar to an ileostomy) instead of their rectum and anus. I thought that was very interesting. We educated her on a mix of a SBS and ileostomy diet depending on her symptoms and output from her ECF. Additionally, if their output starts to trend up and there is nothing in their diet that would increase their ECF output (ex: high sugar beverages) you can consider anti-motility agents. It was very cool thing to learn about! If you are interested in this and are able to have access to ASPEN they have a great article on ECF and nutrition.

- Kaitlyn Kivi

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Hi everyone. I'm a bit confused about protein recommendations in patients who have had partial or total gastrectomy and gastric bypass (especially RYGB). As their stomach acid is decreased and transit time affected, how does their body compensate for reduced protein breakdown prior to arriving in the small intestine? I've had multiple patients at my last job who came to me years after having bariatric surgery only to become severely malnourished and unable to tolerate most protein containing foods (despite regularly taking their prescribed vitamins and meeting their protein goal, albeit mainly through supplements by the time they see me). How can we as dietitians work to help reduce the long term risk of malnutrition in these patients? - Kristina Eggener

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I wanted to share a tidbit from my work in infants and children with short bowel syndrome. It's always important to really find out how much and what part of the bowel was removed or how much remains. This is critical since every short bowel syndrome child behaves differently. I found the information on fiber use to be really interesting...and also confusing. From the Part 2 article by Carol Rees Parrish and John K Dibaise, it mentioned the use of fiber to bulk stools to thicken stools and therefore hopefully decrease the number of stools per day. However fiber can also pull fluid away from the body and may decrease absorption of nutrients and water soluble vitamins. We have had good success with adding fibers especially from the use of real food based formulas in improving stools frequency and consistency and have been able to transition patients of amino acid based formulas (after time where their gut has adapted more) to these food-based formulas I believe because of their fiber content. The use of fiber in short bowel patients who still have some of their colon can also provide additional calories as bacteria produce short chain fatty acids while fermenting this fiber. We also always start with the introduction of vegetables over fruits in infants with short bowel syndrome to provide fiber without the added sugars in fruits. --Tracy Solomons

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I learned a lot from this module!  In terms of ostomies, I hadn’t known that there were multiple types of ostomies that could be created; the double barrel technique of creating the ostomy for healing before reattaching the segments to restore normal bowel function is amazing to me; I almost had the impression that ostomies are created with permanence in mind, so I am glad that my impression has now changed! (A last tidbit that I found so interesting is refeeding bile that has drained after a cholecystectomy and that patients can drink it by mixing it with a soda! This is so fascinating to me). -Kinzie Matz 

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I learned a lot from this module!  In terms of ostomies, I hadn’t known that there were multiple types of ostomies that could be created; the double barrel technique of creating the ostomy for healing before reattaching the segments to restore normal bowel function is amazing to me; I almost had the impression that ostomies are created with permanence in mind, so I am glad that my impression has now changed! (A last tidbit that I found so interesting is refeeding bile that has drained after a cholecystectomy and that patients can drink it by mixing it with a soda! This is so fascinating to me). -Kinzie Matz 

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Hello! I have previously heard of the Whipple surgery and knew it was a very high-risk, extensive procedure involving the pancreas, but I never knew many of the details regarding the surgery itself. I did not realize just how much was removed (parts of stomach, duodenum, jejunum, lymph nodes, head of pancreas, common bile duct, gallbladder). Because of this, it makes sense that one would experience issues such as delayed gastric emptying, dumping syndrome, DM, lactose-intolerance, PEI, and micronutrient malabsorption). -Kelsey Eisner

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Hi Jill,

On any given month I typically have 4-5 patients who are s/p ostomy surgery-about ½ of which have had colostomies.   When I counsel them, I emphasize the importance of chewing their food well as it is well known that hard to chew foods can cause blockages of the ostomy At my facility, we have access to the Academy of Nutrition and Dietetics’ (AND) Nutrition Care Manual, and, I noted that about eight months ago, they posted a new handout on colostomy nutrition therapy (prior to that their only ostomy handout posted was for ileostomies).    The AND handout for colostomy makes no mention of the need to increase dietary sodium intake.  I think this is something that is not much of an issue with colostomies, but it is a significant issue for ileostomies.   The handout does recommend a fluid intake of between 8 to 10 cups per day with higher amounts recommended during hot weather.   AND also advises people with ostomies to eat their largest meal in the middle of the day to decrease stool output at night and promote a good night’s sleep and that missing meals causes the intestine to be more active and increase gas and watery stools.   The colostomy patient is advised to try one new food every three days and to keep a journal recording how the food was tolerated.   If the food is bothersome, it recommends avoiding it for 2-3 weeks and then trying it again in smaller amounts.   Regarding vitamin and mineral supplements, it suggests not to use “gummy” supplements as they are not absorbed as well as chewables, suggesting that a daily multivitamin with minerals and a chewable or liquid calcium supplement be taken daily (although the amount of calcium is not specified).   Regarding fiber, the handout says to avoid high fiber foods right after surgery as the bowel is swollen and avoiding fiber will help it heal.    The fiber restricted diet plan should provide no more than 13 grams/day.   Once the bowel is healed, it recommends to gradually introduce high fiber foods into the diet.  Foods that may discolor stools include beets, foods with red dye, asparagus, broccoli and spinach.    Foods that help relieve odor include buttermilk, cranberry juice, yogurt with active cultures, and parsley.    When I counsel patients, I tell them that no two ostomy patients are exactly alike with what they can tolerate and that it is a matter of paying attention to what you are eating and the symptoms you experience after eating.  Hope this is helpful!  - Karen Brokken RD CNSC

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Jill Endres - Are there good guidelines for the nutrition management of uncomplicated colostomies?  Other than liberating salt intake, maintaining hydration, and watching gas-producing foods, do you make any recommendations for these patients beyond those for the general population?  Probiotics?   Sloan Kettering has a nice resource for patients. Diet Guidelines for People With a Colostomy | Memorial Sloan Kettering Cancer Center (mskcc.org)

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This information describes dietary (eating and drinking) guidelines to follow while your colon is healing. It also explains how to manage common side effects of having a colostomy.

General Eating and Drinking Guidelines

Follow these guidelines for the first few weeks after your surgery. This will help keep you comfortable while your colon heals.

Eat small meals often. Try to have 6 small meals throughout the day instead of 3 large ones.

Eat slowly and chew your food well.

Drink 8 to 10 (8-ounce) glasses (about 2 liters) of liquids every day.

Eat mostly bland, low-fiber foods. For more information, read the "Recommended foods" section.

When you add foods back into your diet, introduce them one at a time. For more information, read the "Adding foods to your diet" section.

Before you're discharged (released) from the hospital, a clinical dietitian nutritionist will talk with you about these guidelines. After you leave the hospital, your doctor and an outpatient clinical dietitian nutritionist will help you as you go back to following your usual diet.

Recommended foods

It's best to eat mostly bland, low-fiber foods for the first few weeks after your surgery. Bland foods are cooked, easy-to-digest foods that aren't spicy, heavy, or fried. Eating bland foods will help you avoid uncomfortable symptoms, such as:

Diarrhea (loose or watery bowel movements)

Bloating

Gas

The following tables include examples of bland, low-fiber foods. If you have questions about foods not listed in these tables, call 212-639-7312 to talk with an outpatient clinical dietitian nutritionist. You can reach a staff member Monday through Friday, from 9:00 am to 5:00 pm.

* If you have diarrhea after having these products, try non-dairy milks, lactose-free cheese, or lactose-free yogurt instead.

** When trying eggs, start with a small amount (such as 1 egg). Eggs may cause a bad odor (smell) when you open your pouch.

* When trying fish and nut butters, start with small amounts. These foods may cause a bad odor when you open your pouch.

Foods to include in your diet

Low-fiber foods, such as:

White bread, pasta, and rice

Bagels, rolls, and crackers made from white or refined flour

Cereals made from white or refined flour (such as Cream of Wheat®, Rice Chex™, and Rice Krispies®)

Foods to limit

High-fiber foods, such as whole grains (whole wheat bread, brown rice, bran cereal, quinoa, and buckwheat)

Foods to include in your diet

Low-fiber foods, such as:

Well-cooked vegetables without skins or seeds (such as peeled potatoes, peeled zucchini with the seeds removed, and peeled tomatoes with the seeds removed)

Lettuce

Strained vegetable juice

Foods to limit

High-fiber foods, such as raw vegetables (except lettuce)

Some vegetables may cause gas or a bad odor for some people. If a certain vegetable causes you to have gas or a bad odor, don't eat it. For more information, read the "Guidelines for Managing Common Problems" section.

Foods to include in your diet

Low-fiber foods, such as:

Pulp-free fruit juice (except prune juice and grape juice)

Peeled fruits (such as a peeled apple)

Canned fruits (except pineapple)

Fruits with thick skins. Examples are:

Soft melons, such as watermelon and honeydew

Oranges without seeds or membrane (the thin clear or white part around each section)

Ripe bananas

Some fruits may cause discomfort for some people. If a certain fruit causes discomfort, don't eat it. For more information, read the "Guidelines for Managing Common Problems" section.

When eating fats, start with a small amount. Fats may cause discomfort.

Reading Nutrition Facts labels

You can find the amount of fiber in your food by looking at the Nutrition Facts label (see Figure 1). Nutrition Facts labels can help you compare the nutritional information between different foods.

Figure 1. Fiber information on a Nutrition Facts label

Adding foods to your diet

After your surgery, you may have some food intolerances that you didn't have before surgery. A food intolerance is when eating a certain type of food causes uncomfortable symptoms, such as diarrhea, bloating, gas, or bad odor. Sometimes, food intolerances go away as your colon heals.

When you add foods back into your diet, introduce them one at a time. If a certain food causes uncomfortable symptoms, don't eat it for a few weeks. Then try it again. No two people will react the same way to food. You'll learn through experience which foods, if any, you shouldn't eat.

For more information, read the "Guidelines for Managing Common Problems" section.

High-fiber foods

Your first follow-up appointment will be about 2 weeks after your surgery. At this appointment, your doctor will tell you if you can start adding high-fiber foods back into your diet. Doing this will help make your bowel movements bulkier (more solid).

When you start adding high-fiber foods back into your diet, do it slowly. Only add one food at a time. Make sure you're also drinking enough liquids. Aim to drink 8 to 10 (8-ounce) glasses (about 2 liters) of liquids every day.

Guidelines for Managing Common Problems

This section has guidelines for changing your diet to help manage common problems. You don't need to follow these guidelines unless you're having the problems listed.

If certain foods caused discomfort before your surgery, they'll still cause discomfort after your surgery.

Diarrhea

Diarrhea is having loose or watery bowel movements, having more bowel movements than what's normal for you, or both. Diarrhea can be caused by:

Certain foods

Skipping meals

Food poisoning

An infection in your intestine

Antibiotics (medicines to treat infections) and other prescription medications

A blockage in your intestine

If you're having diarrhea, follow these guidelines:

Contact your doctor's office. They may give you a medication to help.

Drink 8 to 10 (8-ounce) glasses (about 2 liters) of liquids throughout the day.

Drink sports drinks (such as Gatorade or Powerade) and oral rehydration solutions (such as Pedialyte®), if you can. These drinks will help keep you from becoming dehydrated.

If you don't have these drinks, you can make your own using these ingredients:

4 cups (32 ounces, which is about 1 liter) of water

1 cup (8 ounces) of orange juice

8 teaspoons (40 milliliters) of sugar

1 teaspoon (4 milliliters) of salt

Put all ingredients into a cup with a lid. Shake well so the sugar and salt dissolve (melt).

Don't eat the following foods and drinks. They may cause diarrhea.

Eat more of the following foods. They may help thicken your bowel movements. * These foods are whole grains. You can eat them if you're having diarrhea because they may help thicken your bowel movements.

Constipation

Constipation is having fewer than 3 bowel movements per week, having hard bowel movements, having a hard time passing bowel movements, or all 3. Constipation can be caused by:

Certain pain medications

Certain anti-nausea medications

Not eating enough fiber

Not exercising enough

Not drinking enough liquids

If you're constipated, follow these guidelines:

Contact your doctor's office. They may give you a medication to help.

Drink hot water with lemon or lemon juice, coffee, or prune juice.

Do light exercise (such as walking), if you can.

Ask your doctor if eating high-fiber foods or taking a fiber supplement will help.

Gas and odor

For the first few weeks after your surgery, it's common to have gas in your pouch and a bad odor when you open your pouch. You may have more gas if you had a robotic surgery.

If you're having problems with gas or odor, talk with your wound, ostomy, and continence (WOC) nurse. You can also follow these guidelines:

Don't do these things. They can cause gas.

Chewing gum

Drinking with a straw

Smoking or chewing tobacco

Eating too fast

Skipping meals

Ask your healthcare provider if you can take an over-the-counter medication (such as Beano® or simethicone) before meals to help prevent gas.

Eat less of the following foods. They may cause gas, bad odor, or both.

Eat more of the following foods. They may help prevent gas, bad odor, or both.

When to Call Your Healthcare Provider

Call your healthcare provider if you have any of the following:

Diarrhea and a fever of 100.4 °F (38 °C) or higher

Diarrhea and you're vomiting (throwing up)

Diarrhea that doesn't stop after 24 hours

Diarrhea and smelly discharge (fluid), or forceful liquid output from your stoma

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Diet Guidelines for People With a Colostomy

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This information describes dietary (eating and drinking) guidelines to follow while your colon is healing. It also explains how to manage common side effects of having a colostomy. Follow these guidelines for the first few weeks after your surgery. This will help keep you comfortable while your colon heals.

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Hello Classmates!   For this assignment, I chose to share a tidbit of practice knowledge that I have found when providing MNT to post-gastrectomy patients.  I have taught the post-gastrectomy diet for more than three decades.  When I teach this diet, I emphasize the importance of eating small frequent meals/snacks including protein-rich foods, avoiding foods high in concentrated sugars, and limiting liquid intake to 4 ounces at mealtimes, consuming additional fluids between meals.   Since, I like to provide my patients with the most up to date information possible, I decided to look for post-gastrectomy diet information from other websites.  One of the best handouts, I came across was one called “Eating After Your Gastrectomy” from Memorial Sloan Kettering Cancer center.  https://www.mskcc.org/cancer-care/patient-education/eating-after-your-gastrectomy.  This handout provides very comprehensive information including recommendations for B12 supplements, lactose intolerance, portion sizes, strategies for dining out, label reading, and six days’ worth of sample menus.   Reviewing this handout made we realize something that I wasn’t including in my MNT – the fact that soluble fibers are beneficial in managing diarrhea.   I realized that prior to this my teaching was focused on the type of carbohydrates that cause dumping syndrome (concentrated sweets) and not on how foods such as bananas, peanut butter, and oatmeal, can help control the diarrhea associated with dumping syndrome, which I now plan to address when I teach this diet.  In the near future, I hope to update my institutions handout to include recommendations I learned from the Memorial Sloan Kettering Cancer center.

-Karen Brokken RD CNSC