Reality ET: Dietary Considerations After Ostomy by Mary Lou Boyer, BSEd, RN, CWOCN

Cleveland Clinic Florida, presented April 4, 2004

The Big Questions: What can I eat? What should I eat? Food is an important part of our lives and because of that one of the first questions patients ask, whether I am seeing them before surgery or after surgery is, “What will I be able to eat?”
Well the good news is that there is no particular diet for a person with an ostomy. There are no specific “do’s” and “don’ts” but at the same time I can’t just give a straightforward answer such as “EVERYTHING” . In most cases this is true, for most people with an ostomy there are few, if any, restrictions. However everyone is unique and can tolerate different things. Some can tolerate everything and others need to be more careful. You might have even found out that you can actually tolerate more now than you could before surgery. Points to Consider: What surgery did you have? What was the reason for your surgery. What other problems affect what you eat? What pre-existing conditions/restrictions are present such as diabetes, cardiac disease, allergies, or other medical problems.

However it is important to always consider what the actual surgery is, what it is for, (in other words what was the diagnosis and reason for your surgery) and what other factors are involved – what other problems do you have that can affect what you eat. Each individual patient needs individual counseling and information, however there are general guidelines that may be used for all patients.
First of all I ask is there a particular diet that you have been on. If your diet has been restricted because of Diabetes or cardiac disease, allergies or some other medical problem, then you need to stick to those restrictions regardless of whether you have had ostomy surgery or not.

Right After Surgery: Immediately you’ll be given NPO or nothing by mouth. Pain will be noted; where, when, how much? You may have altered taste, decreased appetite and be put on a low residue diet.

After we have that part out of the way, we can then get down to the important discussion of what to do after surgery.

It takes a long time for your digestive system to fully recover after surgery so you may have noticed at first that you were not very hungry and felt full almost as soon as you started to eat. It takes a while for you to feel hungry but it is important to eat a well balanced diet to maintain good nutrition and to keep bowel activity normal. Years ago the belief was that a patient with an ostomy must restrict fiber intake. When research demonstrated how important fiber and good overall nutrition is, modifications were made in the post-op instruction. Now we ask our patients to avoid foods high in fiber (such as raw vegetables, nuts, corn, or any foods with skin or seeds) only for the first two weeks. Low residue or soft foods pass more easily through your intestines while they are healing. Keep Informed: Find out what part of your bowel was removed and how it affects your diet and absorption.

Nutritional Needs: Protein – repair and healing; Fats – energy and cell rebuilding; Carbohydrates – energy; and Vitamins and minerals – cell development.

Reality ET’s recognize Fear Factors as: Gas, Odor, Diarrhea, Dehydration, and Food Blockage.

Gas. Its major sources are: Swallowed air – use of straws, talking while eating, chewing gum, smoking. Gas formed by foods (bacterial action on undigested carbohydrates). Foods That May Cause Gas are: beer, carbonated drinks, milk / milk products, strong cheeses (such as Roquefort and Brie), eggs, broccoli, brussel sprouts, cabbage, cauliflower, corn, cucumbers /pickles, beans, radishes, spicy foods and very cold fluids.

What to Do: Find out what foods cause gas for you. Try each separately to see which causes a problem (If any of these foods are your favorites try eating smaller quantities). Omit these foods or eat selectively at times when flatulence will not cause embarrassment. Avoid gulping food too fast. Eat slowly / chew food thoroughly. Be sure dentures fit properly and that your teeth are in good condition. Avoid skipping meals. More gas is produced by an empty bowel. Stir some of the carbonation out of problem beverages before drinking them. Yogurt helps cut down on gas. Avoid smoking and chewing gum. Postnasal drip increases swallowing air. Muffle flatus sounds by putting pressure against stoma with hand, arm, or elbow. Cough at the same time or look around you to see who else was making the noise. Use charcoal filters to vent gas. Ask about gas reducing products such as Gas X, Beano.

Fear Factor Number Two. Odor: Odor should not be a problem except when you change or empty your pouch. Foods that may cause odor in stool or urine are: fish, eggs, asparagus, onions, some spices, vitamins, broccoli, cabbage, turnips and certain medications.

Odor: What To Do: Alter your diet. Urostomates should drink more water. Avoid offensive foods. Foods that minimize odor: yogurt, buttermilk, cranberry juice, orange juice, applesauce, parsley, and mint. Try room sprays using them both before and after emptying your pouch. Pouch deodorants (for use in the pouch) can be added into your pouch after emptying. There are commercial deodorants and perineal cleansers available. Some ostomates use mild mouthwashes in the pouch.
Oral Deodorizing Agents (that can be taken by mouth) are Bismuth subgallate (Devrom) or Chlorophyllin copper complex (Nullo, Innermint). These must be take consistently to be effective and you should check with you doctor before trying to make sure there are no unwanted effects or contraindications. The best measures are a secure, odor-proof pouch and good hygiene. Check fit and type of pouch. If you experience odor other than when emptying, your pouch may need to be changed or re-fitted. Be sure to keep your pouch tail and closure clip or spout clean.

Fear Factor Number 3. Diarrhea: What is normal? What is diarrhea? Diarrhea is having more liquid stools occurring more frequently than normal. It is caused by illness, stress, certain medications (e.g., antibiotic therapy, antacids containing magnesium), environmental factors, certain foods, chemo or radiation therapy
Foods that may cause diarrhea or loosen stool are: green beans, broccoli, cabbage, spinach, raw vegetables, raw fruit, milk, beer, excessive coffee or other caffeinated beverages, fruit juice, prune juice, grape juice, chocolate, licorice, large amounts of candy, diet candy containing sorbitol, large meals, and high volume of fluids with meals.

Foods that can thicken stool or slow diarrhea are: applesauce, boiled white rice, ripe bananas, creamy peanut butter, tapioca, bread, weak tea, mashed potatoes, oatmeal, cheese, yogurt, pasta, pretzels, ginger snaps, boiled milk, cream of rice, and marshmallows.

It is very important to realize that you cannot slow or stop the bowel or bladder from working by not eating or drinking. If you have a colostomy and usually irrigate, stop irrigations until diarrhea subsides. Use a drainable pouch. Diarrhea can lead to severe dehydration and should be taken seriously. Return to a low residue diet while having diarrhea and try to prevent dehydration by replacing fluid and electrolytes. Contact your doctor if diarrhea persists.

Replacing Fluids and Electrolytes: A rule of thumb is to drink a glass of replacement fluid each time pouch is emptied. Try replacement drinks such as sports drinks, fruit or vegetable juices (V8), broth, or Cera Lyte. Electrolytes (sodium and potassium) are lost when the body loses a lot of water. Foods containing potassium are orange juice bananas and tomato juice. If diarrhea is caused by antibiotics or bacterial imbalance, replace the normal intestinal flora (bacteria) with yogurt, buttermilk, acidophilus, or VSL#3.

Fear Factor Number 4. Dehydration: Dehydration occurs when you are losing more fluid than you can take in. It can result from: prolonged diarrhea, vomiting, excessive sweating from fever, hot weather or exercise. No matter whether or not you have an ostomy and no matter what type of ostomy you have you can get dehydrated.

Signs and Symptoms of Dehydration: Dry mouth, excessive thirst, abdominal cramping, low urine output, dry skin, fatigue or tiredness, headache, cramping or tingling sensation in hands or legs, muscle cramps, sunken eyes, nausea and vomiting, dizziness, feeling faint, shortness of breath or confusion.
Dehydration: What To Do: Increase your fluid intake, especially electrolyte replacement fluids such as Gatorade, Cera Lyte, soups, bouillon, or tea. Eat low residue foods that help slow stool output. Replace potassium with bananas or orange juice. Use a little extra salt on your food to replace sodium. Contact your physician who may want to start you on anti-diarrheal medications.

Try this recipe for homemade electrolyte replacement: 1 tsp salt, 1 tsp baking soda, 1 tsp white Karo syrup, 16-ounce can frozen orange juice, Add water to make one quart, mix well.

Fear Factor Number 5. Food Blockage: A food blockage is an intestinal obstruction caused by eating high fiber foods too quickly or in large amounts. It is characterized by: cramping, abdominal pain, a thin watery output or flow of waste which may stop completely, increased odor of stool, abdominal swelling, stomach area swelling and/or vomiting.

Foods that may cause a blockage (high fiber foods) are: celery, coconut, corn and popcorn, chinese vegetables, dried fruits, foods with skins / peels, nuts, mushrooms, raw fruits, raw vegetables, seeds or kernels, meats with casings (skins), coleslaw, shrimp, lobster, oysters, clams, mussels, or other shellfish.

What to do if you have a blockage: Try taking a warm tub bath to relax abdominal muscles. Gently massage abdomen or around stoma area. Lie in a knee-chest position. If your stoma is swollen, remove your pouch and replace it with a pouch with a larger stoma opening. If you are able to tolerate liquids, increase fluid intake by sipping small amounts at a time. Gulping fluids too rapidly may push food mass more tightly together.

Notify your physician if: Your blockage symptoms persist; You are unable to tolerate or replace fluids; or if the signs and symptoms of fluid and electrolyte imbalance occur.

Tips to Help Avoid Blockage: Avoid high fiber foods for two weeks after surgery. Add high fiber foods to your diet one at a time. Chew food well to make it easier to digest. Avoid swallowing large bites of meat or vegetables. Remove skins of fruit if you are prone to blockage. Anything too tough to cut is probably too tough to eat. Corn kernels on the cob can be slit with a serrated knife before eating. Juice fruits and vegetables in a juicing machine. Consider taking a whole food concentrate such as Juice Plus+®.

Maintaining Health and Wellness: “Diet Talk” is everywhere. Be careful with fad diets and fad foods. Eat a well rounded diet. Moderation is the key. Natural vitamins are more beneficial than are artificial. Make sure supplements are readily absorbed. Be careful with herbal preparations. Take only medications prescribed for you. Tell your pharmacist, dentist and any physician that you have had bowel resections so they can prescribe or dispense the right kind of medication for you.