36-47 owm0608 lambert · absorption of essential vitamins, minerals, ... ture search was conducted...
TRANSCRIPT
36 OstomyWound Management
FEATURE
Asurvey of the Fort Worth ostomy association
found the majority of the members are >65
years of age. Many have had their ostomies for
more than two decades.1 Thus, people who have had
significant bowel resections such as ileostomies,
ileoanal pull-throughs, continent diversions, and
colectomies are living long enough to have to deal
with some of the same degenerative diseases and con-
ditions commonly encountered by all older adults. Of
particular concern: Does living with an incomplete
intestine increase risk for age-related disabilities such
as osteoporosis?2
The intestine seems to adapt to surgery and resec-
tions. Generally, the physiology of vitamin and miner-
als (absorption from the resected intestine and subse-
quent use by the body) requires adequate nutritional
intake, including enzymes and specific hormones in
amounts sufficient to process the nutrients. Even with
as little as one third of the small intestine present, the
body continues to maintain adequate vitamin and
Does Intestinal Resection Affect theAbsorption of Essential Vitamins,Minerals, and Bile Salts? An Overview of the LiteratureGeraldine M. Lambert, RN, DBA, CWOCN
As the number of persons living long lives following ostomy and bowel resection surgery increases, so do their questions aboutthe effect of surgery on chronic conditions commonly associated with aging. The literature was reviewed to evaluate currentevidence about the effect of bowel resection on the absorption of vitamins and minerals and related health concerns such asosteoporosis, gallstones, and renal calculi. Present knowledge about the process of vitamin and mineral absorption in theintestine and clinical study results suggest that chronic inflammation and corticosteroid use may adversely affect absorption.In general, a history of bowel resection does not appear to increase the risk of developing osteoporosis, gallstones, or renalcalculi and the body can adjust to losing significant sections of intestine. Strategies to help prevent the majority of long-termcomplications should be encouraged, including monitoring hydration and transit time, consuming low-digestible carbohy-drates, and avoiding processed foods as well as agents with chelating properties.
KEYWORDS: ostomy, nutrient absorption, osteoporosis, gallstones
Ostomy Wound Management 2008;54(6):36–47
Ms. Lambert is an enterostomal therapy nurse, JPS Health Network, Fort Worth, Tex. Please address correspondence to: GeraldineM. Lambert, RN, DBA, CWOCN, 320 Fossil Rock, Azle, TX 76020; email: [email protected] or [email protected].
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June 2008 Vol. 54 Issue 6 37
mineral stores as long as the patient maintains a
healthy diet.3 However, loss of the distal ileum and
colon can affect bile salt production. Changes in
nutritional absorption have been found to cause
higher numbers of gallstones among patients who
have short bowel syndrome than among the normal
population.4 Calcium-related renal stones also are
more common among persons with significant
reductions in bowel length secondary to increased
transit time of effluent, which results in dehydration
and concentrated urine output.5
Clinicians, caregivers, and patients need to know
whether significant changes resulting from bowel
resection increase the risk of osteoporosis, gallstones,
and renal stones in persons with a stoma. Because
mineral absorption in people with ostomies was a
concern of the members of the Fort Worth Chapter
of the United Ostomy Association (UOA), a litera-
ture search was conducted to determine if intestinal
resection with loss of significant portions of the
intestine can affect absorption of vital nutritional
elements. The most productive searches resulted
from using the word calcium in combination with
Crohn’s or inflammatory bowel and yielded English-
language articles published between 1989 and 2007;
most involved retrospective research. The literature
search focused on the anatomy of the intestine, the
physiology that affects mineral and bile salt absorp-
tion, and whether intestinal resection can result in
latent deficiencies of essential vitamins and minerals.
The results of the literature search, first pre-
sented to the UOA Fort Worth chapter
members, are summarized to help clinicians
optimize care of all persons with a stoma.
Anatomy and FunctionThe intestinal tract comprises the stom-
ach, the small intestine, and the large intes-
tine or colon. Alcohol, some medications,
and simple carbohydrates are absorbed
directly from the stomach. Each section of
the intestine is responsible for the absorp-
tion of a particular nutritional element.
Small intestine. The small intestine in the
adult is approximately 22 feet long and con-
sists of the duodenum, the jejunum, and the
ileum. The small intestine wall is arranged in folds of
absorptive cells and villi. Most nutrient absorption
occurs in the small intestine,6 including minerals, vita-
mins, proteins, and fats. Iron, calcium, magnesium,
and zinc are absorbed almost immediately after leav-
ing the stomach — ie, in the 8 feet of the duodenum
and the jejunum. Sugars and vitamin C, as well as thi-
amin, riboflavin, pyridoxine, and folic acid, are
absorbed in the upper third of the small intestine.
Protein is absorbed approximately midway through
the ileum. Vitamins A, D, E, and K, fats, and choles-
terol are absorbed in the lower third of the ileum.
Vitamin B12 is absorbed just before the small intestine
joins the large intestine. Bile salts are reabsorbed in the
distal ileum and the ascending colon.3
Large intestine. The large intestine (colon) is
responsible for reabsorption of water, sodium, potas-
sium, and vitamin K. However, retrospective studies
have shown that the large intestine also is responsible
for absorption of small amounts of calcium and mag-
nesium. Ohta et al7,8 injected magnesium and calcium
directly into the large intestine of rats through a cecos-
tomy tube. Calcium, magnesium, and phosphorus lev-
els in the feces, urine, and femur were measured by
spectrophotometer; it was found that a small amount
of calcium and magnesium was absorbed by the large
intestine and absorption amounts increased slightly
when oral ingestion of the minerals was withheld.
Absorption. Immediately following removal of
portions of the small and large intestines, the body
KEY POINTS• In industrialized countries, population life expectancy as well as life
expectancy of persons with a history of bowel resections andstoma surgery has increased substantially.
• To help answer questions and prepare new patients for a long lifeafter stoma surgery, the authors reviewed the process of vitaminand mineral absorption and available information regarding threecommon long-term concerns among ostomy patients.
• In general, the body appears to adapt very well — especially ifpatients adopt simple dietary strategies to help prevent long-termcomplications.
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experiences problems with absorption. Disrupted
release of enzymatic secretions and an unusually rapid
increase in the gastric emptying account for the mul-
tiple loose stools that occur with new resections.9
Depending on the portion of intestine removed, the
patient may need at least 1 year for the bowel to return
to normal function. The bowel stabilizes because the
proximal portion of the ileum has a greater capacity
for absorption than the distal portion.
A person can lose up to one half of the distal ileum
and still maintain a normal diet; digestion and
absorption of nutrients occurs basically within the
first 100 cm of jejunum.3 A review of the literature3
has shown that once the patient with an ostomy is
consuming regular food, the small intestine expands
and lengthens slightly to increase absorption. After
approximately 1 year, most people with ostomies are
able to control the consistency of the effluent and
absorption of most of the needed nutrients returns
to normal. Total parenteral feedings do not produce
the increase in ileum circumference and do not pro-
mote increased reabsorption.
Minerals. Three major factors affect mineral
absorption: the solvency of the mineral, transit time,
and the intestine’s ability to absorb the nutrient. Other
factors that can affect the absorption of nutrients
include emotional stress,10 chronic diarrhea, oral
antibiotics, and corticosteroids.
The cilia that line the small intestine are responsi-
ble for nutrient absorption. The bacterial flora found
in the intestine breaks down nutrients.11 Emotional
stress is known to have a destructive effect on the cilia
and antibiotics can destroy the normal flora.
Destruction of the cilia and the flora results in copious
amounts of diarrhea. Diarrhea increases transit time
and reduces the absorption of nutrients. Diarrhea also
can be the result of loss of intestinal tissue, medica-
tions (eg, sorbitol-containing products), diet, and
chronic malabsorption of nutrients.11 Antidiarrheal
medications should be taken only on physician rec-
ommendation and are contraindicated in persons
with colitis and other infectious diarrheas.12 Klein and
Jeejeebhoy11 recommend loperamide to reduce transit
time related to mechanical diarrhea because it is
metabolized quickly by the liver, making it available
faster than codeine and diphenoxylate.
Physical impairments to absorption. The cecal
valve prevents backflow of stool into the small intes-
tine, slows transit time into the large intestine, and
prevents bacteria in the large intestine from contami-
nating the effluent in the ileum. Loss of the cecal valve
complicates the absorption process. Overgrowth of
bacteria from the large intestine increases the destruc-
tion of vitamin B12 and iron and hampers carbohy-
drate and protein metabolism. The lack of nutrient
absorption secondary to an incompetent cecal valve
results in abdominal pain and loose stools.11
Diarrhea secondary to increased transit time is
common immediately after surgery and, for ileostomy
patients, can be an on-going problem. Persons with
ileostomies are known to suffer from chronic poor
absorption of nutrients, putting them at increased risk
for dehydration. Depending on the amount of small
intestine surgically removed, loose watery stools and
increased transit time can reduce the absorption of
fats, proteins, and vitamins. Because vitamin B12 is
absorbed at the lowest portion of the small intestine,
persons with an ileostomy and urostomy also are at
greater risk for the development of pernicious anemia.
Ileostomy and urostomy patients should talk to their
physicians about periodic testing for vitamin B12 defi-
ciency.13 Starting oral food intake and maintaining a
well-balanced diet are extremely important in pre-
venting loss of minerals and other nutrients.
Medications. Corticosteroids have multiple effects
on the body’s metabolism. Long-term steroid use is
known to cause thinning of the bone and the skin.
Moreover, steroids decrease absorption of vitamin A
through the gut, which can be especially detrimental
to wound healing. There is some evidence in the liter-
ature,14 as well as clinician experience, to suggest that
patients with chronic non-healing wounds who are on
steroid therapy may benefit from a vitamin A com-
pound placed directly into the wound.14
Other medications that affect absorption (especial-
ly of vitamins A, D, E, K, and B12) include cholestyra-
mine and other bile acid-binding resins.4 Selected
diuretics increase calcium, magnesium, potassium,
and zinc excretion in urine. Prednisone decreases cal-
cium absorption. Sulfasalazine decreases folic acid
absorption.11 Deficiencies in folic acid can result in
mucosal changes in the intestinal lining.
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Calcium AbsorptionThe chemical absorption of calcium through the
gut and the use of calcium to produce bone minerals
are complicated processes. Calcium absorption is
dependent on magnesium levels, vitamin D levels,
proteins, and parathyroid levels. The parathyroid
hormone regulates the amount of calcium absorbed
from the intestine and the amount of calcium lost
from the bones.15 This hormone also affects vitamin
D levels, which actively stimulate the absorption of
calcium.16 Calcium absorbed through the intestine
binds with the protein calbindin. All of these ele-
ments have to be present in adequate amounts to
maintain bone strength.
Certain medications — particularly aluminum-
containing antacids — affect calcium absorption,
binding to the calcium; if used for prolonged periods,
they contribute to bone thinning.7 In terms of solven-
cy, calcium citrate is more easily absorbed that calci-
um carbonate.15
Abnormal acid-base balances also affect blood lev-
els of calcium and magnesium. Cloutier and Barr18
proposed a theory regarding acid-base balance — ie,
high protein diets increase the amount of calcium lost
through the kidneys. The researchers reviewed multi-
ple studies and suggested that changes in protein
ingestion (either increasing or decreasing the intake)
affected acid-base balance of the body, subsequently
affecting calcium absorption. A (Japanese) retrospec-
tive study7 involved fructooligosaccharides (simple
carbohydrates and sugars) that appear to enhance fer-
mentation in the intestine, lowering the pH in the
intestinal tract and stimulating increased passive and
active mineral transport of magnesium and calcium.
Influence of magnesium and parathyroid func-tion. Several studies indicate that 20% to 50% of chil-
dren with insulin-dependent diabetes (IDDM) have
significant bone loss. The defining factor appears to be
low magnesium levels. In a study by Saggese et al,19 23
children with IDDM were told to eat various concen-
trations of magnesium and calcium. Serum levels of
parathyroid hormone, magnesium, calcium, and vita-
min D were compared over a 60-day period.
Fructosamine levels also were measured and remained
stable. Magnesium was shown to be the catalyst that
controlled absorption levels, playing an essential role
in enzyme activity related to cellular metabolism.20 No
correlation was made between children and adults
with diabetes because the amount of calcium needed
varies by age.21
Determining the calcium balance. Calcium bal-
ance is the difference between the ingestion of dietary
calcium and dermal, fecal, and urinary losses of calci-
um. The simplest way to assess mineral levels involves
blood samples. However, normal lab values in the
plasma are not conclusive, given the body’s capacity to
maintain a normal equilibrium.19 The body will main-
tain normal plasma levels by pulling the minerals it
needs from any available source, including bone.
Therefore, plasma levels may be normal while bone
density is decreased.22 Adding the measurement of
fecal calcium increases the accuracy by determining
the loss of minerals secondary to malabsorption.2
Body mass indices, bone scans, bone density indices,
and dual-energy x-ray absorptiometry (DEXA; two-
view, low-dose radiation exposure x-rays of the lower
spine and hips) provide increasingly accurate bone
health information.2
Conditions Related to Malabsorption Osteoporosis. Osteoporosis is a disease charac-
terized by thinning of the bones. Fractures fre-
quently occur in the spine, pelvis, and long bones.
Osteoporosis has long been associated with
menopause because low estrogen levels result in
increased bone reabsorption.2 However, the current
theory is that bone strength is established during
young adulthood. If bone strength is not maximized
during these critical years, a higher likelihood exists
for fractures as a part of the natural aging process.23
Age-related osteoporosis is the result of both exces-
sive bone reabsorption and defective bone formation.
Magnesium and calcium, as well as zinc and copper,
absorption changes with age. Magnesium and calcium
intake by the elderly has been reported to be far below
recommended dietary levels. Low zinc levels can affect
protein absorption, which has an indirect effect on
calcium levels. Low copper levels also affect bone
strength through collagen depletion.21
Crohn’s Disease (an inflammatory bowel disease)
and bowel resection with or without stoma forma-
tion, have long been associated with osteoporosis
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and increased potential for fractures.24,25 However, the research on
the relationship and causes of osteoporosis in persons with these
conditions has been inconclusive. The prevalence of osteoporosis
depends on the population studied; in patients with inflammatory
bowel disease, it has been reported to range between 12% and 44%26;
according to 2007 US statistics from the National Osteoporosis
Association, 55% of persons 50 years of age and older are at risk. Van
Hogezand25 reviewed a number of studies relating to intestinal dis-
ease and osteoporosis. Results indicated that fewer than 50% of sub-
jects had decreased bone density, either in the form of osteoporosis
or osteopenia.
Although steroids are known to cause thinning of bone, patients
with inflammatory bowel disease have been known to show signs of
bone thinning even before beginning steroid treatment. In a study27
of 32 men, 22 to 32 years of age, newly diagnosed with inflammato-
ry bowel disease and evaluated before receiving corticosteroid ther-
apy, nine (28%) were found to have decreased bone mass. The study
concluded that patients with low body mass and inflammatory
bowel problems for more than 6 months are at greater risk for bone
mass loss.
Van Hogezand et al28 have conducted extensive research related to
Crohn’s disease. One retrospective study involved 146 patients (61
men, 85 women; mean age of 43 years) with Crohn’s disease (mean
duration 20 years) who were receiving a variety of therapies includ-
ing corticosteroids. Among participants, 66% had undergone ileum
resection. According to the authors, “ileum resection was the most
predictive factor for osteoporosis: RR3.84 (CI 1.24–9.77, P = 0.018),
followed by age: RR1.05 (CI 1.02-1.08, P <0.001).” However, follow-
ing a review of seven studies,2 a definite relationship between bowel
disease, bowel resection, chemical treatment, and loss of bone mass
could not be established. Nevertheless, frequent bone mass assess-
ments in patients with inflammatory bowel disease, Crohn’s disease,
and intestinal resection, as well as those undergoing steroid therapy,
are recommended.2 A healthy diet during the young adult years may
help prevent late life bone health complications.
In a review of the literature, Lee et al29 conclude that bone loss is
related to a combination of factors that include the disease itself and
associated inflammation, high-dose corticosteroid use, weight loss
and malabsorption, a lack of exercise and physical activity, and an
underlying genetic predisposition to bone loss.
Kung et al30 discuss the concept that osteoporosis is genetically
related. According to the authors, women in Hong Kong generally
have a low average calcium intake of <500 mg/d. A study evaluated
25 women with low bone density who had experienced vertebral
fractures, 25 age-matched post-menopausal women without frac-
tures, and 15 healthy pre-menopausal women. Over a 6-month
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period, four distinct phases of increased (600-mg
and 1,200-mg supplements) and decreased (300-mg
and 500-mg supplements) calcium ingestion were
monitored. Calcium levels were assessed through
blood and urine samples during each phase of the
study. Bone mineral density (BMD) was measured
by dual-energy X-ray. The study concluded that
intestinal calcium absorption was not significantly
different between pre- and post-menopausal
women. Although the researchers found lower plas-
ma vitamin D levels and higher urinary calcium lev-
els among the older female population, the final
conclusion of the research team was that osteoporo-
sis is genetically determined — that female mem-
bers of osteoporotic families have a significantly (P
<0.05) altered bone turnover response to acute
changes in calcium intake. Subsequently, the net
balance in bone turnover was significantly (P
<0.005) lower than that of the healthy control sub-
jects (P <0.05). An important part of the study con-
cluded that calcium absorption through the small
intestine is not affected by increasing the calcium
dosage or absorptive ability of calcium by the gut.
Gallstones. Production of bile acids for the
breakdown of nutrients is another complicated
chemical process, involving at least 12 enzymatic
steps to convert cholesterol to bile acids. The
process is controlled by multiple factors, including
nutritional status and the condition of the digestive
system. Bile production starts with the presence of
food in the stomach. As soon as the stomach emp-
ties, the gall bladder releases bile into the small
intestine. Bile salts combine with amino acids, cho-
lesterol, fat-soluble vitamins, lipids, and metal ions
(eg, iron and calcium) as they travel through the
small intestine and the ascending large intestine.31
At various times in the digestive process, bile salts
are conjugated (soluble) and unconjugated (insolu-
ble). The majority of bile salts are reabsorbed in the
distal end of the small intestine. A small amount of
the bile salts are absorbed in the ascending large
intestine. In normal intestinal tracts, only a mini-
mum of bile salts is lost through feces and the
process is so efficient that very little bile is lost from
the blood supply. The same bile salts are re-
processed by the liver and excreted back into the
gall bladder, on average, between three and 12 times
a day. Although considered very rare, short bowel
syndrome and hemicolectomy involving the ascend-
ing colon can affect the re-absorption of bile salts.17
One study documented a high prevalence of gall-
stones following colectomy in a sample of dogs.32
Ten dogs were subjected to proctocolectomy and
over a 12-week postsurgical period, bile and serum
were collected. Seven dogs developed gallstones.
The study concluded gall stone formation was the
result of increased unconjugated (water insoluble)
bilirubin in the gall bladder bile. When the distal
ileum and colon were removed and the bilirubin
could not be reabsorbed, the liver increased the pro-
duction of insoluble bilirubin from five- to 20-fold,
providing the basis for increased gallstone produc-
tion. The researchers also found increased acid lev-
els and increased ionized calcium in the bile of the
colectomized dogs.
Bile salts also affect the absorption of water and
the production of mucus to lubricate feces. Bile acid
diarrhea results from malabsorption of bile salts,
increased fluid loss, increased bacterial activity in
the large intestine, and increased lipid and choles-
terol loss through the intestine. Conversely, chronic
constipation can result from excessive absorption of
bile salts, fluid, and loss of mucus. Finally, reduced
bile salt production affects the absorption of fats
and fat soluble vitamins, leading to chronic malnu-
trition. Calcium salts also may precipitate out and
not be absorbed into the system. In mild cases, bile
acid secretion may be normal in the morning
because of replenished reserves during the night but
decreases as the day progresses.17
Renal stones. A 20-year retrospective study5
involving 1,941 patients with renal stones included
patients who had Crohn’s disease, ulcerative colitis,
ileal bypass, ileal resection, and total colectomy.
Study results indicated that patients with bowel
issues have less urine output secondary to increased
intestinal transit time. The increased concentration
of urine was a factor that contributed to stone for-
mation. Increased transit time also led to a mildly
acidic state that increased the excretion of magne-
sium and calcium into the urine. A review33 of four
cases involving three colectomies and one ileal
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resection describes the complex nature of chronic
inflammatory processes, low urine volume, and
increased acid balance as the source of increased
occurrence of renal stones. Thus, calcium supple-
ments should be taken with food to enhance proper
absorption and reduce the potential for calcium to
enter the kidneys and form kidney stones.7
Lifestyle StrategiesTransit time. Slowing transit time gives the
intestine more time to absorb fluids. Diet is a major
educational focus for persons with increased transit
time of fecal effluent. Healthy eating usually
becomes a way of life for people with Crohn’s
Disease, inflammatory bowel disease, diverticulitis,
or stomas. The need to prevent blockages and diar-
rhea is a major concern.25
Probiotics. Probiotics34 are live micro-organisms
that are beneficial for improving intestinal flora. Six
major types are found in the intestine; of the six, aci-
dophilus (Lacto-bacillus) is probably the best known
although not the most effective. Lacto-bacillus appears
to help prevent colitis. The authors suggest that Lacto-
bacillus might be beneficial in Crohn’s Disease, active
pouchitis, and some other inflammatory bowel dis-
eases. Yogurt, milk, and active yeast products also pro-
vide live anaerobic bacteria to the gut. Saccharomyces
boulardii has been shown to reduce antibiotic-induced
diarrhea.35 Persons with severely compromised immune
systems should consume probiotics with care because
an overgrowth of intestinal bacteria can occur.36
Low-digestible carbohydrates. Low-digestible car-
bohydrates (example: Nutriose FB™, Roquette,
Lestrem Cedex, France) have many beneficial effects,
especially on energy intake, digestive physiology, and
mineral absorption as well as an ability to reduce
intestinal transit time.37 The drawback of these low-
digestible carbohydrates is increased flatulence.
Vermorel et al37 studied 10 healthy men for 31 days to
determine the effects of adding low-digestible carbo-
hydrates to their diets. The researchers found that
adding 50 g DM/day of low-digestible carbohydrates
to the subjects’ diets reduced transit times without
causing gastric distress.
Sports drinks, on the other hand, contain high
concentrations of sugars that can increase transit
time. Chemically balanced liquids specifically
developed to replace electrolytes (eg, Pedialyte™,
Abbott Labs, Abbott Park, Ill) are the better choice
for rehydration.12 Other healthy foods include
wheat flour, rice bran, olive oil, anti-oxidants, and
raw fruits and vegetables. Green leafy vegetables are
a good source of magnesium. Sunshine is a good
source of vitamin D.12
DiscussionCurrent research suggests that living with an
incomplete intestine does not in and of itself
increase the likelihood of developing osteoporosis.
Calcium, magnesium, and vitamin D are absorbed
immediately after leaving the stomach. The amount
of calcium absorbed is determined by the parathy-
roid hormone and varies as people age. Bone
growth is at its peak in young adulthood. Exercise
and good nutrition are vital to enhancing bone
strength.4 However, because the parathyroid utilizes
only the amount of calcium it needs, taking mega-
doses of calcium and other minerals results in
excretion of excess calcium through the stool, not
absorption.22 The small intestine has a remarkable
ability to stretch and lengthen to provide greater
surface area for absorption. However, this only
occurs on an oral diet. Tube feedings and total par-
enteral nutrition do not accomplish the same goal.3
Acid balance, hormone levels, and proper diet all
work together to maintain normal mineral absorp-
tion. Avoiding processed foods and therapeutic
agents with chelating properties can prevent most
trace element deficiencies.12
Bone thinning appears to be more related to
lifestyle, chronic inflammatory processes, and
heredity than to intestinal issues. Intestinal resec-
tion in people with normal eating habits and nor-
mal effluent output should not be at any higher risk
for vitamin and mineral deficiencies than individu-
als with normal bowel function.31
Similarly, gall stone formation related to intestin-
al dysfunction is rare and generally only occurs as a
complication of short bowel syndrome.17 A survey
done by the Fort Worth chapter of the UOA1 found
that out of 125 members only three had both an
ileostomy and a history of gall bladder surgery.
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Renal stones related to intestinal malfunction are
a result of dehydration, usually secondary to
increased transit time of effluent. Adequate fluid
intake and slowing transit time reduces the risk of
developing renal stones.34
Conclusion Having an ostomy does not necessarily increase
risk for osteoporosis. Osteoporosis appears to be
related to heredity. People with a family history of
osteoporosis should be tested periodically for bone
mass. Nutrition, lifestyle, and exercise appear to be
the important factors relating to vitamin and min-
eral absorption and bone health for people with
stomas. Good nutrition during young adulthood
when bone growth is rapid provides bone mass in
later life. Persons with decreased intestinal capacity
should be able to maintain healthy body functions
by eating properly, exercising, and taking medica-
tions as prescribed. - OWM
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