Understanding ORS - Importance for Hydration & Absorption

Hi guys,

Before I cure IBD and save the world, I need to answer this one first. I've gotten a few requests in my inbox to re-explain the ORS mystery... so here we go!

Everyone knows how important keeping hydrated is, and depending on what parts of your intestine were removed... how challenging it can be for us ostomates. Even with a complete healthy bowel, we don't just drink water and have it absorbed evenly along the length of our small and large intestine (colon). Each section of our bowels absorbs something different, with some overlap along the way. That means each section can only absorb what it's made to absorb, and everything else just flows on by unabsorbed until it gets to the appropriate section. Everything we eat or drink leaves the stomach and enters the duodenum, then flows through the jejunum, ileum, and then through our colon. Along the way, our livers make bile that is stored in our gallbladder that's then secreted by our intestines to help break down what we ate so it can be absorbed along the way. Our body then reabsorbs that bile at the end of the ileum and recycles it. Likewise, water is the last thing to be absorbed, and that happens in the colon. I should say "mostly" happens in the colon, as some water is absorbed in the terminal ileum as part of that overlap I mentioned. But the majority of our hydration comes from what our colon absorbs. So you can see that when you have an ostomy, your ability to hydrate is a function of what parts of your intestine were removed and what's left. Those who have had small bowel removed have issues absorbing vital nutrients (vitamins and minerals) while those whose colon is long gone have issues with hydration (water). So colostomates have it the best of all, depending if any of their colon was removed before being routed out their belly. If you're missing significant parts of both small and large intestine like me, you've got the most challenges.

Now the way each section of bowel knows what it should absorb and what it should let go by to be absorbed somewhere else is in the physiology of the bowel wall. It's not a solid wall at all, but rather a semi-permeable membrane... think of window screen with different size and shaped holes for each bowel section. It's more complicated than that... but that analogy works. So only things that fit through the size and shape of each section of screen can pass through and be absorbed in that bowel section, and everything else is denied entry. So you can see that missing sections of bowel make absorption of some things impossible... or near impossible, and you have to take supplements for those things. Now the body is a wonderful biological machine in that it can adapt to overcome difficulties, but it can't work miracles. So when a section of your bowel is removed, in many instances other sections of your bowel can adapt to absorb what the removed section absorbed. But like I said... there are limits. You can't remove the whole small bowel and expect the colon to do all the work, or vice versa... just won't happen. But the key here is that parts of what you do have left can be tricked into absorbing water... if you know what the key is that unlocks those sections of semi-permeable membrane. Now hold that thought and we'll come right back to it in a second.

The other way we have trouble hydrating is when our colon or large intestine is inflamed. It's typically called diarrhea, but when inflamed the bowel walls swell and can't absorb much. So folks in 3rd world countries that are drinking crap water have problems staying hydrated just like many ostomates. And this is where ORS comes in. The World Health Organization (WHO) developed ORS primarily to help people out who suffered from rampant diarrhea and lived in unsanitary conditions. Lucky for us... it works for ostomates who need it too.

So how does it work? Well, remember that key that unlocks the semi-permeable membrane I told you about... ORS has that key! So since the colon is either missing or inflamed... it can't absorb water. And the small bowel isn't programmed to absorb water... so it won't. But if you know what the small bowel will absorb... you can trick it to pull in water if you mix that water with what it normally pulls in... i.e., what unlocks the semi-permeable membrane lock. So what ORS does is mix together the right ratio of glucose (sugar) and sodium (from table salt) in a specific amount of water. The glucose and salt in the proper ratio diluted properly are what unlock the semi-permeable membrane, which allows the attached water molecules to slip through the membrane... and we get hydrated without using our colon (large intestine) at all. Pretty nifty, eh? I'm oversimplifying, as usual, but that's the easy explanation.

Now there's a nuance to this I might as well bring up that pertains to us short-gutted folks. That ratio of glucose and salt to water is really important for everything we drink... and here's why. Liquids are considered either hypertonic, isotonic, or hypotonic. Hyper means there's too much sugar/salt in it, isotonic means it's just right, and hypo means there's too little. If we drink hypertonic (too much) drinks then our body actually pulls water from our body to secrete into our intestines to try to dilute what we just drank to the proper ratio for absorption. You gotta give our body kudos for trying... but that makes us even more dehydrated because there's nothing downstream to reabsorb all that water, and instead of gaining hydration... we're losing it faster. So sugary drinks are a no-no all the time! Conversely, if you drink straight water, or something with not enough sugar/salt (i.e., hypotonic) it flows right past the membrane and ends up in your bag. Not a biggie except it also washes out all that bile your liver made and that makes your liver work really hard to keep up. And you don't want to stress your liver... it's one of those things you can't live without. So be aware of what you drink all the time, and have your liver function checked periodically.

Hopefully that explains what ORS is and why it's really important for some folks. It's actually very easy to make when you're out and about once you know the ratio of salt to sugar to water. And you can use anything to make it, as long as you keep the ratio right. I will tell you that the WHO has 2 versions of ORS and if you Google them you want to start off with the "Reduced Osmolarity" version. That just means less salt, which makes a big difference in how it tastes. And if you find even that not to your liking just start with whatever amount of salt you can tolerate and slowly build up to the required amount. You'll find your taste buds will adapt easily and eventually everything else will taste weird while ORS tastes just right. So go slow if you need to... but do what you must to stay hydrated! Just let me know if you have any questions, can't find the ratio, or I didn't explain something very well... and we'll get you straight.

:O)

Bob

Hey Bob, excellent job of explaining a complex situation!

Hey Bob, that new pic is gorgeous! ORS comes pre-packaged here, you just add it to one liter of water. I take it if the need arises, but from what you have said, I will take it more regularly. Best wishes.

Bob's back

Just search for St. Mark's solution, I've posted it here several times before, it has worked well for me when I've been on the ropes.

Hi guys, I've had my ileostomy for 30 some years and I've been adding a small dash or pinch of salt to my water and food since my surgeon told me to. But I never would have thought to add sugar. I also add a few drops of lemon concentrate as I also am plagued by kidney stones.

How to Manage Ostomy Leaks with LeeAnne Hayden | Hollister

Yes, St Mark's is a good ORS.......there's lots of them out there. And yes, they come prepackaged nowadays. I was using Drip-Drop for a bit, but ultimately found I like cola flavor. But after trying all the cola flavors, I ultimately ended up making my own from the cheap store brand cola, diet cola, and seltzer. I like Aldi's Summit brand of cola and diet cola, but there may not be an Aldi's near you. Seltzer I get at my local Weis Market supermarket for pennies.......and it's CHEAP ORS. I make 4 liters every morning, and that lasts through the day and when I power-rehydrate in the early AM each.

When I'm not in the mood for carbonation, I simply take a quart of Lemonade Gatorade...not the sugar-free crap, the original sugared version...dump half into another bottle, add a 1/2 teaspoon of salt to each, fill the rest of each with water......and go. LOTS of things to use, just get the salt and sugar right per liter, and you're all set. Experiment!!

;O)

Bob

I'd never heard of ORS before. And I don't really have major dehydration issues. But that was a great post full of useful info that I didn't know. Thanks, Bob. That's much appreciated.

That ORS sachet I mentioned is made by Searle, an American pharmaceutical, and is to be mixed in one litre of water. It contains: sodium chloride 3.50g, potassium chloride 1.50g, sodium citrate 2.90g, and dextrose anhydrous 20.0g. They have a lot of experience with ORS for the simple reason that there is more bacteria floating around in underdeveloped countries than there is in Maryland where you are. That leads to diarrhea and dangerous dehydration, especially among children and infants.

I read about an Englishman with a bag who was very active, always on the move. An expert at changing bags behind trees and bushes. The only time he was nonplussed was on a slow boat to China when he got a terrible case of the runs. The Chinese doctor on board who had never seen a stoma told him that he can give a local remedy or an American or European one. He took the local one and it worked, probably had a bit of ORS in it!

I rehydrate with low sodium V8 juice. It has all of the electrolytes one needs. I get plenty of sugar and sodium through the food I eat. I always have a few cans in the fridge ready to go.

Wow, I had no idea at all about how all this works. I was told to drink more water, which I do. I average about 6 glasses of filtered water a day + a large glass of white cranberry juice + 3 - 4 cups of tea and an average of 2 coffees a day and a pop. I have had very hard output, like trying to pass a golf ball through my stoma. Once passed, there would be hard round poo in the pouch, hard to squish if I squeeze it through the pouch. I called my contact nutritionist and, as he recommended, I added a spoonful of fiber to my cereal and I also tried Metamucil every other day. Now it gets pasty and messy to dump. Bob, all this information you posted (and thanks for doing so in an understandable way) helps me understand what is trying to happen inside my belly. Now I have to learn to adjust. Does salt in food help compensate for lack of salt in water? We use filtered water, using ZeroWater filtering device to help knock off the taste of chlorine in our town's water. Would this be removing other minerals that colon, bowel, or other parts of the digestive system need to absorb water? Bob, thanks for your information and help. Fred

Thank you for taking the time to explain the need for hydration and some of the obstacles we face. I appreciate the information very much. Take good care. Thanks.

Great explanation! I've had my lg. intestine completely removed, and my colon and rectum completely removed. All I have is my small intestine, and as most of you would know I have a very high output ileostomy. I elected to have this done in 2014 because my wife (now ex-wife) and I were expecting our first child and I was going to be a stay-at-home dad. I was diagnosed with Crohn's in 1993, but showed symptoms around 1988 just after graduation. I never went to see a doctor, I was 18 and just thought my excessive diarrhea and cramps were from cheap beer and gas station dinners. So I finally saw a GI doctor and was diagnosed with Crohn's. From the start, my body rejected every medication for my Crohn's situation and after months and months in the hospital, all I was receiving was IV solumedrol and TPN and lipid emulsions. I had total bowel rest for months and had two huge IV bags, one looked like Mt. Dew and the other one like milk, that fed me. Since my body rejected all Crohn's medication, I was only taking huge doses of prednisone and by 1995 I had avascular necrosis and osteonecrosis in both hips and both shoulders. They said it was from prednisone and possibly Crohn's. So in 1996/97, I had both hips replaced. I was 26, a couple of years later both shoulders were replaced. I've had a total of 5 hip replacements since 96/97, the latest one was 3 years ago. Sorry for rambling on about a small portion of my Crohn's surgeries. But since I have only my small intestine, everything runs through me fast. I can't drink any sports drinks or Pedialyte because of the ingredients. They run out of me so fast I actually get dehydrated and start cramping, and if I sweat the same thing happens. After doing lots of searching, I found my cure for dehydration. It's called LYTE SHOW. I get it off Amazon and it's a high liquid concentration of minerals you add to anything. The dose is 20 small drops into a liter of water. That's all I need for the whole day and I don't need it every day. I've been using it for over 5 years and haven't had cramps or been dehydrated since. Before I found LYTE SHOW, I've had to go to the ER many, many times for IV fluids. Most of the time I'd receive 5 to 6 liters. Please Google it. There are other products that are similar, but I've only tried LYTE SHOW. It's a great feeling when you're hydrated and I know that us ostomates have a hard time staying hydrated. Thanks for bringing this up. And I hope my little input can help all who suffer with this situation. GOD BLESS! And Stay Safe!

I have posted about this before, but it bears repeating. If nothing else, it shows that we are not all the same, and what may work for one does not work for others. I got my ileostomy about a year and a half ago and was given an information sheet by the hospital with a recipe for the 'oral hydration' solution that I could make at home. I faithfully followed the instructions and started drinking it daily. Fairly quickly, I noticed I was feeling lethargic and generally not well. Within a few weeks, I started gaining weight, which also did not make me happy. I went to my doctor and after discussing the change I had made to my diet (the oral hydration being the only change), he sent me for bloodwork, which showed my glucose levels were elevated, and more concerning, my liver enzymes were quite elevated. He suggested I eliminate the sugar from the solution, saying that this amount on a long-term basis could increase my risk of fatty liver disease. Too much sugar in the diet is one of the main causes of this disease. I stopped the sugar immediately, and my blood was retested. My glucose was back to normal, and all normal liver enzymes were also back to normal. The weight I had gained also quickly came off. I have had my blood tested regularly since then for all the usual vitamin and mineral levels, and everything has stayed good. He said the amount of sugar in my diet is all I need.

The recipe given out by hospitals and other medical professionals doesn't seem to give any consideration to the fact that we are all different sizes either. Perhaps what I was recommended to drink might have been OK for some 200 lb, 6' 2" man, but it sure was not OK for this 92 lb, 5' 2" woman.

Excess sugar leads to fatty liver disease. That is a fact. Food for thought, at least.

Terry

I have never been told to add sugar or salt to my water and had never heard of this before. I have had my ileostomy for 50 years. I had Crohn's throughout my large colon, rectum, and even appendix, so they were all removed. I have my full small bowel intestine and thankfully never tested for Crohn's. As I understand, the small bowel is what absorbs all of the nutrients, but I wonder how it can when everything flows through within 1/2 hour to 1 hour after I eat. I was recently diagnosed with macular degeneration and was advised to take a supplement AREDS2 to slow the progression. My eye doctor recommended I have a DNA test to see if the AREDS2 supplement would help me. The result was that I should not take it if it contains zinc and that zinc might make my situation worse. I have stopped taking a multivitamin with zinc. AREDS2 is in a capsule form. When I emptied my pouch 1/2 hour after I had breakfast and capsule, I noticed the entire capsule came out too. So now I open the capsule and mix it with either some applesauce or yogurt so that hopefully it will be fully absorbed in my system. Last week I had my bi-annual blood test and my alkaline phosphate was lower than it should be. The description of this being low is that one can be suffering from malnutrition (I am overweight) or I have protein or zinc deficiencies.

Just wondering if anyone here that only has their small intestine has ever experienced seeing that they are passing medications or supplements through their pouch and if so, what do you do about it?

Hi Redondo, I too have an ileostomy, and I was taking all my vitamins with no problem, even the large pills seemed to be getting fully absorbed, but recently I've started to have one of the pills, magnesium, come out undissolved in my pouch. Strangely, the larger multi-vitamin I take is still being absorbed. Maybe it's the time of day I take it? I don't know, anyway, to solve the problem, I'm now taking my magnesium in powder form. All my other supplements, Vit C, D, K2 and glucosamine are in gel caps and I've never had a problem with them.

If you are having even gel caps come out undissolved, it sounds like your transit time is crazy fast. Maybe you could add more foods to your diet that slow down your output, like peanut butter, cheese, things like that?

Terry

Hi fj,

Does salt in food help compensate for lack of salt in water? That's a great question. The answer is sort of. When I started using ORS (I was stubborn as a mule so it took me awhile), I always asked my dietician if I should try to "adjust" my liquid intake to compensate for what I ate. Meaning if I just ate some ice cream, which is full of sugar, should I swallow some salt and water and hope it gets close to the ratio I need to absorb some of it. She said it would be impossible to get that right, and I think she's right. But you don't have to get it exactly right! There is an optimum ratio of glucose to sodium to water, but that doesn't mean varying from that ratio a little in either direction doesn't work at all. It's called a 'gradient' because it's like a probability curve. It would be hard for your body to dump bile or water in exactly the right amount to make what's in your intestines the 'perfect ratio'........because that stuff is moving through your intestines. So if it dumps what would be the perfect amount of bile or water......by the time it does that, the stuff has moved down your intestinal tract a bit and you need a new "key". So there's a gradient in effect which just means the closer you are to the perfect ratio, the more efficient your body will be at absorbing water. But above or below that optimal ratio, you're just less efficient, not totally shut down. So I DO play games with what I eat and drink, figuring close is better than way off base. Now when I do something stupid, like eat a half gallon of ice cream........I know I'm going to pay the price and nothing I can do will fix that........unless I eat a pound of salt and 4 gallons of water....which ain't happening. So in that case, I figure it's best to get the ice cream out of me as fast as possible to limit how much water is pulled from my body to try to dilute it. So typically, I'll chug half a liter of ice water to flush out that stuff as quickly as possible.......as the stomach releases water almost immediately into the GI tract. But don't be stupid like me......eat sensibly! So the best advice I have for you is to experiment. Only you will know what works for you.

I too use Zero Water, but I take supplements for all my minerals. You should ask your Doc to check your micronutrient levels every so often just to make sure you're not needing some supplementation. Personally.....I recommend every ostomate get with a good Dietician (who knows something other than Diabetes) and make sure they're getting the proper nutrition with their ostomy. I know it sounds like a pain in the ass, but if they find something you're lacking........you'll be thanking them. And if you're spot-on then you're buying peace of mind.......which is priceless!

;O)

bob

Hi Red,

Oh yeah.......I can relate. What I do is chew the capsule to where I just feel it break........and then I swallow it. Now you have to be careful because some meds are not supposed to be released in the stomach. If you take one of those and you see the full capsule come out your bag you need to talk to your doc and they can have the pharmacy compound something for you that will release after the stomach, but quickly once in the digestive tract. They make a whole variety of containers (capsules, gel caps, coatings) that release in different locations. So when you see a med coming out whole.......tell your doc and have him/her change the coating/container.

;O)

Bob

Damn Weaver........you've sure been through the wringer, eh? Whenever I read people's stories like yours (and mine) it pisses me off. The medical profession leaves so much to be desired and how many of us have to suffer like you did. I've met so many really bad doctors I can't even count them all. And a scant few really good ones. UGH! Thanks for the info, I'll check it out.

;O)

Bob

Thank you for the advice, Bob. I do take supplements 1 a day over 50 vitamin, and a glass of V8 every day. Regarding micronutrient levels, my recent blood work results were good except for low iron, and I have just been prescribed a pill once a day for that. My doctor told me that meat or beef contains a good dose of iron. I have been selective in what I eat, and lol, Bob, I am not about to eat a tub of ice cream, as much as I would love to. I will work on the balance of salt, sugar, and water as you mentioned, and continue to learn or train my digestive system to work properly. I will continue checking in for good tips such as you have provided. Thanks for your assistance, Fred.

Hi Bob. I am relatively new to the site. I have never heard of ORS before. I have asked my surgeon and team of doctors if there is a diet or something I need to do now since I have a colostomy bag. They said eat how I would normally eat, but take stool softeners/vitamins and drink plenty of liquids since I also have IBS-C and get clogged a lot. Recently I found out I was badly impacted, so they recommended drinking more liquids because I had severe pain in the abs. That is all that was said. I do not eat much sugar or salt. Hearing about ORS is something new to me and wonder if I should do it. I understand what you are saying about nutrients, but wonder if it is for me. I am drinking Ensure for nutrients because that is what they gave me when I had the surgery done.

For ORS, what about water with lemon juice/sugar/salt or any juice? I have a steel thermos that I use solely for water. I hate salt and if there is too much salt for me, food tastes nasty.

Hi subwmn,

First off, welcome to the site... the more the merrier! After reading your comments, I have to say I'm still shocked that new ostomates aren't provided the proper information before (or shortly after) they leave the hospital. I mean, this day and age, that's truly hard to believe. When I got my front-butt back in 2014, it was the same way... lucky for me (in a twisted way), I was on TPN, so I had to be under the supervision of a home health nurse. Now, she didn't know much about ostomies, she was focused on the TPN part of it, but she could answer basic questions about what to eat, etc. Because I was short gutted, I was advised to contact the Small Bowel Transplant team at Georgetown University Hospital, as they were knowledgeable in short gut syndrome. Lucky for me, the coordinator who was assigned to me immediately changed my home health care provider to an awesome group of folks who were determined to get me off that damn TPN before it destroyed my liver. Which you kinda need to stay alive. And part of that was assigning me a fantastic dietician! And I mean, this gal was incredible. I learned more from her than any of the doctors I spoke with, and without her, I can't imagine where I'd be now. With her help, I got off TPN in record time and never looked back.

My point here is that EVERY ostomate should have two people on their team. A Gastroenterologist who knows their shit... and a Dietician (not a Nutritionist) that is well-versed in ostomy patients' needs. And be forewarned that most Dieticians are only well-versed in dealing with Diabetes and Obesity, not bowel issues... so you have to search and ask them point blank when you interview them. But without those two people in your corner, you're basically blind to what your body needs and how you should supplement. And that's why it's amazing to me that they simply give you an ostomy... tell you to eat normally... and send you on your way! Your digestive system has just been hacked to pieces, rerouted, and in most cases, shortened... and you're told to take it slow, be careful, and don't do anything stupid... and have a nice day. Unbelievable!!

So in regards to ORS, whether you need it or not depends on what was removed from your bowel to make you an ostomate. The more that was removed... the more you need ORS. In other words... the more bowel you still have... the more normal your life will be. In your case, it depends on how much of your colon (if any) was removed. If it was a small section, the remaining colon will adapt and you might be fine without any ORS. If they took a lot of it out... you may benefit from ORS.

It's really all about hydration... and I'm guessing your Docs didn't discuss with you how to be aware of your hydration levels. There's a couple ways, with the easiest being the color of your urine. Ideally, it should be clear or very slightly yellow if you're properly hydrated. If it's darker than a pale yellow... you could stand to improve your hydration. The other easy way is the "pinch test". Pinch the skin on either hand on the side of your hand right behind your thumb. Just grab the skin and pull it upward and then let it go. How quickly it goes back to being flat is an indication of your hydration level. Check it when your urine is clear to get a "baseline" of how quickly it returns to flat and then you'll have something to compare to when it takes longer. Check it at different times of the day, as hydration levels vary quite a lot, depending on what you're doing. You'll be surprised how long it takes for your skin to go back to flat if you're not properly hydrated. One tip for your getting bound up... eat more olive oil. Really. When I was obstructed, I learned to take a big swig of it in the morning... and no more obstructing. And it's really good for you too. Do a little research and find one with the highest level of polyphenols. There's a lot that are readily available and cheap. Drink up... but don't forget the chaser... without it, olive oil tastes horrible. You've been warned!!

;O)

bob

Ooops! Forgot to answer your last question. Yes, you can use fruit juice, just note the sugar content of the juice in question and only use the proper amount to get you the 20-25 grams of sugar you need in a liter of ORS. I find 2-3 packets of salt from any fast food place or sandwich shop gets you the proper salt content per liter as well, and I always pilfer a few extra packets to keep in my car. Like I said earlier... you can use anything to make ORS, as long as the sugar to salt ratio is correct for a liter of the ORS. That gives you a lot of leeway to make it from almost anything. I hope this helps... if not... just yell back!!

Regarding dehydration, I went into my colostomy surgery with a low sodium level. It is from being on Lexapro since forever. My internist referred me to a nephrologist who was one of those rare doctors who takes the time to learn about you. He recommended drinking Gatorade as well as water. Within two weeks my sodium level went up 5 pts to the low average. It may be even higher now.
I do, however, drink the "crap" Zero Gatorade because of counting calories. I drink 40 ounces daily along with regular water. I love the orange.
Unlike so many on this site, I do not have a lot of other problems related to my colostomy.

Mine was elective because of a severe case of IBS-C. Improved quality of my life immensely.

Thank you for posting this - really appreciated.

Best wishes

Jayne

Pictures please 😁

I drink 2 bottles of Gatorade FIT, every day. It's an electrolyte beverage, only 10 calories. Tastes good. I passed out at work a while back due to dehydration. Fell and hit my head. Spent nearly 2 days in the hospital. Back then I was just drinking water. Doctors advised me to add an electrolyte beverage for better hydration. I'm really happy with the FIT beverage, and feel good. I buy it on Amazon, get it delivered to my house.