In the early postoperative period, ileostomy output will be bilious and liquid. Once solid food is ingested, the effluent thickens but in the early postoperative period, the output is typically 1–1.5 l a day and at this level, some patients will need IV replacement of lost water and electrolytes. In a short time, the small bowel adapts and slows transit to the point that a well-established ileostomy will consistently put out only 200–700 cc per day with 90 % of the output being water. Within about 6 months of construction, the volume of ileostomy output will vary little and the effluent will be a yellow-brown color with a porridge-like consistency. An ileostomy will function throughout the day, but the bulk of the effluent will come within a few hours after meals. There will be some patients who, based on a number of factors, not the least of which might be disease activity or length of the small bowel, will have chronically high ileostomy outputs of a liter or more a day. These patients will be instructed to try and control the stoma output by using antidiarrheal mediations such as Imodium, Lomotil, or codeine taken just before meals and at bedtime.

In the early postoperative period, patients should be instructed to watch their diet carefully and avoid fibrous foods (generally all raw fruits and vegetables, except bananas). The issue is that there will predictably be edema where the ostomy exits the abdominal wall and fibrous foods that do not digest easily can obstruct the ileum just beneath the stoma site causing what is known as a food bolus obstruction. These are a common cause for early postoperative visits to the office or the hospital. The classic symptoms being cramping just beneath the stoma site and reduced ileostomy output following dietary indiscretion. These food bolus obstructions can usually be broken up and cleared by aggressive irrigation of the bowel, through the stoma, using a 14 or 16Fr red rubber catheter. In the late postoperative period, the diet can be liberated. From a nutrition and metabolic standpoint, in the long term, normal nutrition is the rule. Total body water volume and exchangeable sodium are decreased leading to a slight state of chronic dehydration and perhaps an elevated serum aldosterone level. However, potassium depletion is rare and calcium and magnesium losses are unaffected. Loop ileostomies (Fig. 28.2) constructed to divert the fecal stream from an ileal pouch to anal anastomosis can be different as they are often constructed in the proximal ileum with perhaps 2–3 ft of distal bowel out of circuit, between the stoma and the ileal pouch to anal anastomosis. These stomas may have a higher output and may lead to nutritional deficits and dehydration. They are, of course, meant to be merely temporary, and the trouble will be resolved when they are closed: typically in about 12 weeks.

A well-constructed end ileostomy will protrude about 1.5 to 2.5 cm above the level of the skin. Given a nice “ileostomy spout” coupled with siting on a nice flat point on the abdominal wall, most ileostomy patients should be able to maintain an appliance for 3-7 days and most patients empty the ileostomy pouch about 4-6 times each day [5, 6].