Tesis

Terapi Medik Gizi pada Pasien Ileostomi High Output = Medical Nutrition Therapy in Patients with High Output Ileostomy.

Ileostomi merupakan tindakan pembedahan pembuatan lubang (stoma) antara ileum dan dinding abdomen, bertujuan untuk pengalihan feses. Ileostomi umumnya dibuat pada pasien yang menjalani penanganan kanker kolorektal, neoplasma stadium lanjut dengan infiltrasi usus halus, maupun peradangan saluran cerna. Ileostomi high output (produksi stoma ileum >1500 mL/hari) dapat menyebabkan gangguan keseimbangan cairan dan elektrolit, maupun malnutrisi pada pasien. Saat ini belum ada pedoman tata laksana nutrisi komprehensif untuk pasien ileostomi high output. Serial kasus ini bertujuan untuk mendukung terapi, mengatasi malnutrisi, menunjang perbaikan klinis, sehingga dapat menurunkan morbiditas dan mortalitas pasien ileostomi high output. Empat pasien ileostomi high output dengan rentang usia 42 hingga 50 tahun mendapatkan terapi medik gizi selama perawatan di rumah sakit. Tiga kasus merupakan kasus kronik dengan keganasan, sementara satu kasus lainnya merupakan kasus akut yaitu adhesi dan perforasi akibat hernia femoralis strangulata. Keempat kasus tersebut merupakan ileostomi high output onset awal, yaitu yang terjadi kurang dari tiga minggu pasca pembuatan stoma. Berdasarkan kriteria malnutrisi American Society for Parenteral and Enteral Nutrition (ASPEN), keempat pasien ini tergolong malnutrisi berat. Terapi medik gizi diberikan dengan prinsip pemberian makanan dan minuman porsi kecil namun sering, restriksi cairan hipotonik, pemberian minuman berupa larutan elektrolit-glukosa, pemberian medikasi anti motilitas, serta koreksi cairan dan elektrolit menurut kebutuhan dan kondisi klinis pasien. Target asupan energi dan protein pada keempat pasien dapat tercapai selama perawatan. Selama pemantauan, keempat pasien mengalami penurunan output ileostomi, serta perbaikan keseimbangan cairan dan elektrolit darah. Satu pasien mengalami perburukan klinis dan meninggal akibat sepsis pada hari perawatan ke-18. Tiga pasien pulang dengan kondisi klinis perbaikan. Satu pasien mengalami peningkatan output ileostomi saat perawatan di rumah, kemudian dirawat kembali sepuluh hari setelah pulang karena komplikasi anemia gravis dan ketidakseimbangan elektrolit, dan pada akhirnya meninggal. Terapi medik gizi dapat menurunkan produksi stoma, memperbaiki kadar elektrolit darah, serta memperbaiki keseimbangan cairan pada pasien ileostomi high output.
Kata kunci: stoma, high output ileostomi, keseimbangan cairan dan elektrolit, terapi medik gizi


Ileostomy is a surgical procedure to divert the ileum onto an artificial opening in the abdominal wall, aimed for fecal diversion. Ileostomy is commonly created in patients undergoing treatment for colorectal cancer, advanced neoplasms with intestinal infiltration, or gastrointestinal inflammation. High output ileostomy (stoma output >1500 mL per day) can cause imbalance of fluid and electrolytes, and malnutrition in patients. At present, there is no comprehensive nutrition management guideline for high output ileostomy patients. This case series aimed to support therapy, prevent malnutrition, improve clinical condition, as well as to reduce the morbidity and mortality of high output ileostomy patients. Four high output ileostomy patients, with a range of age 42 to 50 years old received medical nutrition therapy during their hospital stay. Three cases were chronic cases in malignancy, while the other case was an acute case of adhesion and perforation due to strangulated femoral hernia. All four cases were early onset high output ileostomy, occurring in three weeks after stoma creation. Based on the American Society for Parenteral and Enteral Nutrition (ASPEN) malnutrition criteria, these four patients were classified as severe malnutrition. Medical nutrition therapy was administered according to a set of principles: small frequent feeding and drinking, hypotonic fluid restriction, oral electrolyte-glucose solution administration, antimotility medication administration, as well as fluid and serum electrolyte correction, according to patients' needs and clinical conditions. The target of energy and protein intake in all patients were achieved during hospital stay. During hospital monitoring, decreased ileostomy output as well as improvement in fluid and electrolyte balance were observed in all patients. One patient clinically worsened and died due to sepsis on the 18 th day of hospital stay. Three patients showed improvement in clinical condition and were discharged. One patient experienced an increase in ileostomy output at home, and then readmitted ten days after hospital discharge due to severe anemia and electrolyte imbalance and subsequently died. Medical nutrition therapy may decrease output as well as improve fluid and electrolyte balance in patients with high output ileostomy.
Key words: stoma, high output ileostomy, fluid and electrolyte balance, medical nutrition therapy