The Ostomy Files: Using Intellect and Judgment at the Table

   Animals feed; man eats. Only the man of intellect and judgment knows how to eat. - Anthelme Brillat-Savarin

    Over the years, hundreds of articles have been written about appropriate diets for a person with a stoma, listing specific foods that should be avoided due to the potential for a mechanical food obstruction, diarrhea, constipation, excessive odor, or gas. Many of these publications present lists of foods appropriate for colostomy patients, a separate list for ileostomy patients, another for urostomy patients, and yet another for those with Crohn's Disease or ulcerative colitis. As a result, many healthy, rehabilitated patients become virtual slaves at the table, afraid to eat a particular food because it could cause "problems." This is an unfortunate because in most cases, one of the great benefits of ostomy surgery is the gradual return to the individual's pre-illness diet.¹

    There are, of course, exceptions. Dietary restrictions may be indicated for patients with a short bowel, fistula, severe Crohn's Disease or ulcerative colitis, fluid and electrolyte imbalances, or those undergoing chemotherapy or radiation treatments. Because the diet for a person with a urinary diversion is usually not altered after ostomy surgery, this column will focus on examining unnecessary dietary restrictions often imposed on individuals with a fecal stoma.

    The major areas of food-related concerns are mechanical food obstruction (particularly for ileostomies), excessive odor, and excessive flatus.

Mechanical Food Obstruction

    If large quantities of high fiber foods (the most common culprits are popcorn, nuts, and corn) are consumed at one time or not chewed well, they can cause a mechanical, or dynamic bowel obstruction. The bowel above the large bolus of fiber becomes hyperactive as it tries to push intestinal contents past the obstruction. High-pitched bowel sounds are heard and peristalsis may be visible on the abdomen. Pressure inside the intestine continues to build. As a result, the intestine below the blockage can collapse on itself. This brings about a reversal of the direction of the peristaltic waves as the bowel tries to empty its contents and relieve the pressure. This causes vomiting. A mechanical obstruction can occur in both the large and small intestine and is a common complication of patients with an ileostomy.

    Often, during an interview with patients who have experienced a mechanical food obstruction, clinicians discover the food ingested before the obstruction may not have been on the traditional "do not eat" list (eg, popcorn, nuts, corn), but rather, a food the patient reports "as always causing a problem." However, the problems are more commonly related to the quantity of high-fiber food ingested and how insufficiently it was chewed. Rather than avoid high fiber foods, patients should be instructed to chew them carefully and limit their intake.

Excessive Odor

    Each individual is aware of certain foods that cause more intestinal odor than others - coffee, asparagus, and garlic typically cause problems for most people - but this varies from person to person. Just because a certain food creates increased fecal odor is no reason to eliminate it entirely from one's diet. Patients should be taught to observe which foods increase the odor of their feces and be judicious regarding when they choose to eat them. Today, many closed-end and drainable one- and two-piece pouching systems contain integral charcoal filers that help deodorize fecal odor. Including yogurt or buttermilk in a meal containing known odor-producing foods is an effective method of reducing fecal odor. Commercially available pouch deodorizers also help reduce or eliminate fecal odor. Before using over-the-counter odor-reducing oral tablets, patients should check with their healthcare professionals.

Excessive Flatus

    Excessive flatus is probably the most common complaint among patients with fecal stomas. Once again, foods that cause excessive gas vary from person to person, but several are common gas-producing foods such as cabbage, carbonated beverages, beans, cucumbers, broccoli, and dairy products. These foods need not be arbitrarily avoided but can be consumed judiciously. Pouching systems with filters help keep the pouch deflated under clothing and deodorize the flatus as it is released from the pouch. Over-the-counter products, such as Beano (GlaxoSmithKline, Philadelphia, Pa.) can be taken immediately before or after eating offensive foods to help reduce the amount of gas and odor production. The use of commercially available pouch deodorizers and gas and odor filters on pouching systems all contribute to reducing embarrassment while increasing a sense of security in work and social situations. Patients also should be educated to avoid flatus-producing behaviors such as chewing gum, smoking, and drinking through a straw.

Conclusion

    Patients know best what foods precipitate their problems such as cramping, obstruction, increased fecal odor, or excessive flatus. Keeping a diary of foods eaten for a week or two will help patients clearly identify problem-causing foods. These foods need not be totally omitted from the patient's plate, but instead eaten with discretion in terms of the amounts per meal with attention to thorough chewing. If gas and odor become a problem, the patient can eliminate known gas and odor-causing foods, especially around times when social interaction is anticipated. As stated earlier, ostomy surgery is intended to restore the pre-illness quality of life. Healthcare professionals must help patients with a fecal stoma to regain the pre-illness pleasure and benefits of a balanced diet and good tasting, nutritious food. 

A well-governed appetite is a great part of liberty. - Seneca

The Ostomy Files is made possible through the support of ConvaTec, A Bristol-Myers Squibb Company, Princeton, NJ

1. Hunker EM. Nutrition therapy for the ostomy patient. In: Broadwell DC, Jackson BS, (eds). Principles of Ostomy Care, St. Louis, Mo.: CV Mosby Company;1982:233-240.