Ileostomy Output: Liquid vs. Apple Sauce Consistency

Hi everyone.
I'm 2 weeks post-surgery, trying to get used to this very new life.
I have a quick question, wondering what longtime ostomates think here.

My doctors and nutritionists in the hospital kept telling me that I want an ‘apple sauce' consistency output. Mine is liquid, and I'm happy about it. Way easier and faster to empty liquid than apple sauce.
Why would I want a thicker consistency if I can have it liquid? What are the benefits this way or the other?

Thanks

Clara 

Hi Clara

Watery output can be an issue because it can be easier for output to find its way between your skin and the appliance, instigating a leak and reducing time between changes. However, this does not apply to everyone all the time; mine tends to move between looser, to just like rainwater at times. There are a number of factors that will produce very loose output, such as drinking too much water too fast, as it will probably pass straight through; coffee can do the same and can contribute to dehydration. Many foods create loose output as well. Others have issues with output that is too firm. There are things such as psyllium husk powder, loperamide, and some foods which can firm up output, but I find the foods inconsistent, so I don't chase them. Looser output also has a self-cleaning action when emptying too 😂

You are still very early in the process and your body is still trying to work out what is going on and will for a while longer. In time, you will learn what works for you.

Two weeks is very early; at that stage, you're eating normally, so loose output is normal. As you start your normal diet again, it will probably firm up more. Just standard advice saying output should be like apple sauce or porridge. I think when they say it, they're thinking more about dehydration from high output. My ileostomy output used to be very solid for the first 15 years, then 20 years ago I lost a lot of my small bowel and have had very loose, watery output ever since. It's never been a problem.

Clara, as your ostomy normalizes after the initial few months, you will find that your diet will dictate how thick or watery your output is.  Some foods will thicken it (potatoes gets me, for example) and others will thin it out (milk products).  I feel like if it's too watery too much of the time that I'm losing too much fluid in the output and that can risk dehydration.  But it's always going to fluctuate throughout the day.

I had my surgery 13 days ago, and mine still alternates between fluid and semi-solid. I use a drainable ostomy bag, and draining it is still something that takes time for me to get used to :(

It was easy when I was in the hospital; the nurses would clean it out, but now that I am out of the hospital and have to do it myself, it is quite tricky! It is indeed easier when it's just liquid, but the bag becomes heavier and kind of pulls on the skin attached to it.

Stories of Living Life to the Fullest from Ostomy Advocates I Hollister

I agree, emptying is definitely something I’m not used to and not sure I’ll ever be totally ok with it. It’s a big deal… 

Thank you Henry, Ben and Axl. Appreciate your replies. 
How long does the early days stage last? I know I’m super early at the moment, but wondering how long it will take my body to adjust? And does it get easier once my body adjusts? 

Your adjustment period has both physical as well as psychological components.  We're all different, obviously.  A positive attitude will be a benefit.  And yes, it'll get easier.  Hang in there, kid.  

Hi Clara, I agree with the others about prolonged liquid output contributing to dehydration. This is most likely why you were told how to thicken it up. I understand your saying that liquid output is easier to take care of and it is - pour out, clean, done (I tend to like this, too!) Over time, everything will even out and you'll notice your output responding to the foods you eat. Yes, applesauce to thicken and I would add butternut squash soup, too. Just try not to be liquidy ALL of the time, rehydrate with water, and add a little salt to your diet.

Thicker output means more nutrients have been absorbed.

With a near flush stoma in a belly fold which is rather difficult to keep a wafer attached, I much prefer watery output so the stoma doesn't extend much and disturb the careful seal I've created to keep a bag on long term.

I do drink plenty of water and an electrolyte drink occasionally. I ensure I'm urinating and it's a normal yellow or clear, not dark orange or dry which would indicate dehydration.

As a new Ileostomate, you may find my next paste of information beneficial.

Gas is usually a diet issue as digestive enzymes breaking down your food produces gas as a byproduct. However certain foods cause more gas than others. A list is provided as part of my paste guide below.

Could be a reaction between meds as well. 

Nighttime dumping is just a fact of life with those who have an Ileostomy. But there are things one can do to reduce the nighttime dumping and get some sleep.

1: With a good bag on, eat from am to about 2 pm. Frequent small and nutritional meals. After that only very small hunger avoiding tiny snacks. This will give time for your stoma to clear out and not fill the bag during the night as much.

2: Sleep only on your back with your upper body slightly raised, with pillows under each arm to train yourself to remain put. This will avoid a lot of issues and cause content to drain to the bottom of the bag.

3: Train yourself at night to tap your bag to check if a dumping is required. Feel around the stoma if a pancaking bubble is forming because if ignored it will force the wafer off and cause a leak or a blowout even.

4: After each dumping, put in a couple of drops of liquid antibacterial dish soap into the bottom of your bag followed by some water and gently (don't squeeze!) wash it out. Follow by two rinses where one (if necessary or in the case of pancaking) lay down and massage/rinse the upper part of the bag and dump. Then perhaps a final rinse. Leave a drop of the dish soap and a tiny bit of water in the bag to control future odor. Say goodbye to stinky bags!

5: Clean stoma area in shower using nothing but antibacterial liquid soap (kills infection of weeping wounds also) and after each spewing as it contains oils that interfere with adhesion, apply nothing else. Blow dry area very well so even wounds feel very dry to the touch. Adhesives like rings, paste, wafer flanges and barrier strips only stick to clean, dry, dust and oily free skin. Alcohols used get trapped under things and cause allergic reactions. Antibacterial liquid soap works best to kill infection and clean the skin of oils, drys out wounds to allow bonding. As long as nothing else added to it at factory, why I prefer to use antibacterial dish soap free of any aloes or skin lubricants. 

6: If you use paste, consider using no-sting paste free of alcohol. Premix some paste with stoma powder to get it to activate and spread a 1/2" thin ring around stoma focusing on wounds first using a flat stick to press it down. If it doesn't stick then remove, and discard off stick using toilet paper. Blow dry and try again. Then about 1/3" away from stoma, put two thick rings of paste, score the tops and sprinkle in a little stoma powder, mix and cover any powder with paste or it interferes with bonding to skin and wafers.

7: If you use a ring, stretch to the size of your stoma and any gaps you press the ring flatter and closer to the stoma to cover the skin. Rings are good for flat areas and good clear skin. Paste is better for unevenness, wounds, dips or graneolumas on the skin.

8: With a wafer hole cut to be just a hair bigger than your stoma (cut an oval if your stoma is oval) press the wafer on and ensure paste or the wafer does NOT cover the stoma or it will clog. You can test fit the wafer and make reference marks on the edge of the flange and ones skin to line up later with. Some weaken their wafer horizontally so it flexes some for bending so it's not so stiff, like for belly folds.

9: Diet and quantity control is important for those with an Ileostomy.

Signs of a clogged stoma.

No output or only watery output under pressure for a few hours after eating. Could be caused by a covered stoma by improper application of an appliance, typically hole is cut too small or not lined up correctly or paste covering the stoma. Also could be caused by eating hard food. Remove appliance if necessary and wait in shower washing output away. If badly clogged a severe pain will appear and a trip to the ER is necessary.

Unfortunately very high and frequent output will ensue after clearing for quite some time which will likely making putting on a replacement appliance difficult. Use stool thickening tactics (below). If going to an ER, bring your own otosmy gear and a change of clothes as hospital likely doesn't carry or doesn't know how.

What is "pancaking?"

Pancaking occurs when a vacuum in the bag (likely do to a clogged filter) or super thick stool blocks stool from depositing to the bottom of the bag. Thus can force bag off and cause leaks. Controlling what one eats and by mixing and consuming stool thickening and stool softening foods at the same time in your mouth to get a balance. For instance eating toast mixed with tea in your mouth so the dry bread is soaked and the tea causes more runny stool. To resolve a pancaking issue is to go dump, then flush the bag with two drops of antibacterial dish soap and water, then add fresh water and seal up, go lay on your back and get the water up near your stoma and gently massage the pancaked output loose. Do not squeeze the bag or try to dislodge pancaking output by pressure as that can cause the wafer to detach as well.

What is "ballooning?"

Ballooning occurs when foods eaten produce too much gas and the filter gets clogged (likely due to laying down) and thus forces bag off and causes leaks. You can "burp" the bag of excess gas while dumping or just opening it up a little and pressing the gas portion out. But the best control method is diet control.

These two conditions can cause premature bag replacement and leaks which burn the skin. It's better to replace the appliance if there is any continuous stinging pain, don't just live with it. Keep an eye on your otosmy supply and have ample reserves.

I've found that caffeine, in coffee, tea and even chocolate causes diarrhea and can assist in controlling flow so stool is more liquid..however coffee makes output very acidic making burns far worse. Dried Chinese Crispy Noodles, Cheerios or applesauce (peeled apples) are the exact opposite, a stool thickening food. By mixing these with other foods one can manipulate their stool output and counter the issues above. Also the severe thickening helps in cases where one has severe diarrhea and unable to reattach a new bag due to high flow.

Eating Guide

Partially copied from my nutritionists guide. Ileostomy Nutrition Therapy from the Academy of Nutrition and Dietetics. (This handout may be duplicated for client education.)

My recommendation is to see a nutritionist for the full guide as not all can be pasted here

I've added my own observations to further clarify 

Chew all foods well to the consistency of paste.

Foods That May Cause Blockage (very bad avoid!)

Apples, unpeeled (unpeeled and applesauce are excellent thickeners, don't eat the skins or the core, chew well)

Bean sprouts

Cabbage, raw

Casing on sausage (inside fine if no tough parts, avoid swallowing if a chunk is felt) Also sausage like meats like pepperoni and salami contain indigestible bits.

Celery (avoid)

Chinese vegetables (stir fried crunchy, too hard, need very soft veggies with no skins)

Coconut

Coleslaw

Corn (grits also, corn anything doesn't seem to dissolve in stomach)

Cucumbers (skins bad, inside chewed up good seems okay, no seeds)

Dried fruit, raisins

Grapes, blueberries etc. (skins and seeds the problem.)

Green peppers (red, yellow also) pureed or very very small seems okay in small amounts 

Mushrooms (doesn't dissolve in stomach) pureed or very very small seems okay in small amounts 

Nuts (totally avoid)

Peas (mushy interior okay, like pea soup, skins a problem)

Pickles (skins a problem, inside if chewed up good seems okay, seeds not)

Pineapple (liquid okay, mushy parts fine, hard parts not, rather risky as parts of mushy may not digest)

Popcorn (totally avoid)

Relishes and olives

Salad greens (diarrhea nightmare too)

Seeds and nuts (avoid)

Spinach (doesn't digest, pureed perhaps)

Tough, fibrous meats (for example, steak on grill, well done, tough parts especially, over grilled chicken or dry pork chops. Juicy grilled or pan fried chicken, shredded pork in juices, medium rare steaks, hamburger better.

Vegetable and fruit skins, (any avoid)

Whole grains (no grits, rolled oats oatmeal seems to be okay, oat cereal is an excellent thickener)

Foods That May Cause Gas or Odor

Alcohol, Apples, Asparagus (stink), Bananas, Beer, Broccoli (clog hazard)

Brussels sprouts (clog hazard)

Cabbage (clog hazard)

Carbonated beverages

Cauliflower, Cheese, some types

Corn (clog hazard), Cucumber

Dairy products

Dried beans and peas (clog hazard)

Eggs (don't digest in stomach)

Fatty foods

Fish (cooked salmon in small portions may not, nor stink, same for raw tuna)

Grapes

Green pepper (red and yellow also, clog hazzard)

Melons, Onions (clog hazard)

Peanuts (clog hazard) Prunes

Radishes, Turnips

Soda and sipping using straws, (drink from glass instead)

Seafood (oh God does it stink!)

If your having pancaking issues a small amount of something above (like having a soda during a meal) could introduce some air into your diet and thus into the bag. Also by avoiding too much thickening foods by themselves which often contribute to pancaking.

Foods That May Help Relieve Gas and Odor

Buttermilk, Cranberry juice, Parsley

Yogurt with active cultures (Greek yogurt)

Foods That May Cause Diarrhea (looser or more frequent stool)

Alcohol (including beer)

Apricots (and stone fruits)

Beans, baked or legumes

Bran, Broccoli, Brussels sprouts

Cabbage, Caffeinated drinks

Chocolate

Corn (in my experience corn anything doesn't digest in stomach, just passed through and out, kernels/popcorn will clog)

Deep Fried meats, fish, poultry (KFC, supermarket rotisserie chicken very bad, and anything soaked in brine)

Fruit juice: apple, grape, orange (small amount okay)

Fruit: fresh, canned, or dried (small amount okay)

Glucose-free foods containing mannitol or, sorbitol

Gum, sugar free

High-fat foods, High-sugar foods

High salt foods (KFC, supermarket rotisserie chicken)

High seasoned foods (like blackened)

Licorice

Milk and dairy foods (small amounts okay)

Nuts or seeds (bad, clog hazard)

Peaches (stone fruit, one rarely okay)

Peas, Plums (stone fruit)

Prune juice or prunes

Soup

Spicy foods

Sugar-free substitutes

Tomatoes, Turnip greens/green leafy

Vegetables, raw

Wheat/whole grains, Wine

Rice (very soft 1/4 cup in mixed in food okay), refried beans (1/4 cup okay) pasta (one cup max).

Any foods soaked in brine or deep fried (rotisserie chicken, Kentucky fried chicken etc)

Solent nutritional meals 

Foods That May Help Thicken Stool

Applesauce (unpeeled apples, no cores)

Bananas, Barley (when OK to have fiber)

Cheese (processed cheese food a clog problem, use real cheese)

Dried Chinese Crispy Noodles (severe thickening, mix with other food that causes diarrhea)

Marshmallows

Oatmeal (when OK to have fiber)

Pasta (sauces may increases symptoms) (in my experience more than a cup of pasta causes diarrhea)

Peanut butter, creamy only, nuts clog (may make skin greasy)

Potatoes, no skin (skin clogs, more than a cup may cause diarrhea)

Pretzels (salty may cause more flow water consumption)

Metamucil, mix or crackers (mix in cup of water and drink before it gells up)

Hi Clara,  Ditto what everyone else has said.  I have an ileostomy, and agree that liquid output is easier to deal with as far as emptying goes, but does become more problematic when out and about, simply because the more liquid in your output, the more volume, so your pouch will become heavy and need emptying more often.  Not always easy when out in public.  You also risk having absorption issues with long term liquid output, as everything can pass through you so quickly, your body isn't able to absorb all the nutrients it should.  My output varies throughout the day and night and depends a lot on my diet and liquid intake.  You will get there and find where you are comfortable and what works for you.  It's early days.  

Terry

I am a lot like Terry in that my output changes in consistency throughout the day. A further caution to liquid output in addition to dehydration issues, if you are quite liquidy, the transit time in your intestines is pretty fast. If you are taking meds, sometimes it is so quick that pills don't get a chance to dissolve. Shamrock mentioned a number of foods that would help thicken your output; try a few and see what works best for you. I like applesauce, potatoes, and bananas.

Thank you so much for your replies. It is early days and I alternate between being grateful that I’m post surgery and regretting the fact I ever did it…. 
Thanks for your tips, I appreciate it. 

All this is making me think of something else now, if foods pass through an ileostomy so fast that even pills can be undigested how does it work with calories? Do we absorb less calories from foods we eat with half the digestive system out of the picture? 

I currently use a small and big bottle with a long spout. I use the small one for when I just want to clean really quickly or when I wake up at 3 a.m. and just want to go back to sleep asap 😆

I use the big bottle (to use it, you turn it upside down and the spout has holes on its end so it sprays water and you just have to squeeze the bottle to spray water inside the bag) for a thorough cleanup.

But I think I might have been too eager in cleaning it because the skin around my stoma is a bit itchy and irritated.

According to my doctor, yes, we absorb only around 30-40% from the food we eat; that's why he advised me to eat more than before. For those with a reversal colostomy, he also said once it is reversed, people tend to put on weight because they have been used to the habit of eating more. 😅

In the very early days, I would find tablets in the bag. The doctor said to crush them in a mortar and pestle, for example, and put them in a little water and drink it to avoid them passing through before dissolving. It works well but tastes like crap. Check with the doctor first, as some medications may cause issues with this process. As for calories, who knows? I am naturally slim, but there are all shapes and sizes of people with an ostomy.

I think this may be wishful thinking Clara!  Would be nice.  I did lose a lot of weight after all my surgeries (4), but once it was all over and I stabilized, I put it back on again.  I don't think I'm any different now than I was pre-ostomy, I still need to keep active and watch what I eat, or I do start to gain weight.

Terry