Diet and Ostomies
Question:
I have had an ileostomy for 4 months now. Before I went home, the dietitian told me about foods that I should stay away from for 6 weeks after my surgery so that I don’t get bowel blockages. I am still afraid to try other foods. Do you know what foods are safe for me to eat?
Answer:
Diets for people with new ostomies have been a longstanding source of confusion and (sometimes) fear: people are unsure of which foods to restrict, for how long those restrictions must be maintained, and why restrictions are even necessary. Meal times can become a source of worry rather than enjoyment. This article will attempt to explain some of the principles of diet restrictions for people with new ostomies.
Little research has been done to support the need for specialized diets after stoma surgery. Most of the suggested dietary changes are the result of understanding how the bowel responds to surgery, how certain foods are digested in the gastrointestinal system, and from years of anecdotal reports from patients and their health care team as to which foods may/may not cause problems. Old surgical techniques, which often resulted in a strictured (narrow) stoma, may also have been a source of dietary modifications.
The primary concern is right after surgery when the bowel is swollen. The bowel dislikes the manipulation associated with surgery, and swells temporarily. This swelling subsequently narrows the lumen (the inner opening or diameter) of the bowel and may potentially impact how some foods pass through your stoma. When your stoma is constructed, the bowel is pulled through the many layers of your abdominal wall (fascia, muscle, and fat) before being sutured to your skin. These surrounding tissues limit how much your bowel can expand when food passes through to the outside and into your pouch. When this tension is coupled with the initial post-operative swelling of your stoma, the size of the stomal lumen is temporarily smaller and may restrict the passage of specific foods. Typically, the swelling of the bowel takes about 6 weeks to settle down after surgery, and then most foods can be re-introduced with little difficulty.
Short-term food restrictions tend to be associated more with ileostomies than with colostomies. The foods that cause the most concern are those containing cellulose: the natural fibre, or skeleton, that holds fruits, vegetables, nuts, and grains together. Humans lack the ability (through enzymes or acids) to digest these foods in the small intestine. These fibres can be broken down through other means: chewing your foods well, cutting them into smaller pieces, or cooking them to make the food soft (the 3 ‘Cs’). You may notice in the drainage from your ileostomy that foods like carrots, peas, and peaches look no different than when they were swallowed. As a result, for that initial 6 weeks after your surgery, the dietitian may recommend the following modifications to your diet (see Table I):
- Avoid raw fruits and vegetables
- Cook fruits and vegetables until fork tender, chew well and eat small to moderate quantities at each meal
- Avoid fruit skins and seeds, and dried fruit
- Avoid nuts, seeds (unless in a processed form like smooth butters) and popcorn.
Dietitians may also advise that for a short time, food casings (like those found on sausages and cold cuts) should be avoided/removed, and tough grades of meat (like beef) should be deferred for a few weeks.
The challenge with these recommendations is knowing how much is too much. While stating these foods should be temporarily avoided, small amounts are unlikely to cause harm or blockages if consumed: a few sesame seeds on a bagel, a slice of tomato on a hamburger, or a few raisins in a muffin are probably not going to result in a food blockage at your stoma. Larger quantities, however, such as a dinner sized Caesar salad or a large serving of stir-fired vegetables may cause concern.
After the 6 week post-operative period, the swelling should be resolved and you can re-introduce the restricted foods into your diet. Try small quantities of one fruit/vegetable at each meal, chew the food well and watch for symptoms such as cramps, bloating, pain, nausea or vomiting, or changes in stoma output. As foods are tolerated, you can continue to add others. Raw fruits and vegetables can be enjoyed again, as long as these are chewed well. If you continue to have concerns, or are confused about diet progression, contact your dietitian or Enterostomal Therapy Nurse to help guide you back into a regular diet.
For people with a colostomy, dietary restrictions are essentially not required at any point in the post-operative period. In the large intestine, the ‘good’ bacteria that normally live there can partially digest the cellulose, breaking down some of the fibres in the fruits, vegetables and seeds into smaller pieces. Stool from the colon tends to have more bulk, and the stoma tends to be a bit larger in diameter, allowing a larger formed stool to pass. Dietary changes for those with colostomies may be more focused on managing gas and odour.
If you have other dietary restrictions such as lactose intolerance or celiac disease, these considerations remain unchanged and should continue after your stoma surgery. You may want the help of a dietitian to help you merge your usual dietary requirements with the short term needs of your ostomy so that you can ensure a healthy balanced diet.
Table I*
Foods to be avoided by ileostomy patients for the first 6 weeks following surgery*
Vegetables
- Corn, peas, mushrooms (either raw or cooked)
- Bean sprouts, lettuce, cabbage
- Raw carrots and celery (cooked okay)
- Vegetables with seeds (e.g. tomatoes, cucumbers)
- Tough fibrous vegetables (e.g. asparagus)
Fruits
- Fruit skins and seeds (these can be peeled, cooked to a compote)
- Dried fruits, fruit leathers
- Tough fibrous fruits (e.g. pineapple, mango)
Meats
- Tough meats such as beef
- Sausage with casings, or any meat casings (these can be eaten if casings removed)
Other
- Nuts (though smooth nut butters are okay)
- Popcorn (some advocate that this should be a long-term restriction)