1. Enjoying your food again: diet after stoma reversal
Barbara Engel Dietitian

2. liver The small intestine
The small intestine is the longest section of the digestive tract. Food nutrients are digested and absorbed here as food is moved through by peristalsis. (Peristalsis is the wave-like movement of intestine muscles that moves food along the digestive tract.)
The small intestine is about 20 feet long. It is made up of 3 sections:
Duodenum (first part) – 10 to 12 inches beginning at the outlet of the stomach
Jejunum (second part) – about 8 to 9 feet
Ileum (third part) – about 12 feet, connected to the large intestine at the cecum
The large intestine
The large intestine (also called the colon or large bowel) joins the small intestine where the ileum and cecum meet on the body's right side. It is about 5 to 6 feet long, and is made up of these sections:
Cecum –the entry point for food that has been through the small intestine and is now a highly acidic liquid. It contains the ileocecal valve which keeps food from backing up into the ileum.
Ascending colon – the contents are acidic liquid. This section goes up the right side of the body.
Transverse colon – the contents are less acidic liquid. This section goes across the abdomen.
Descending/sigmoid colon – the contents become more formed. This section goes down the left side of the body to the rectum.
Rectum – holds formed stool
The main jobs of the large intestine are absorbing water and electrolytes,(minerals like sodium, calcium, and potassium that the body needs to work normally.), moving stool, and storing waste until it is passed out of the body.
The rectum and anus
The 2 end portions of the digestive tract are the rectum and anus. Special nerve pathways to the brain make us aware when the stool reaches this section. Only at this point do we have any control over part of the digestive process. As the stool enters the rectum, we feel the need to have a bowel movement. The anal sphincter muscle is like a valve that allows us to control this. Unlike the rest of the digestive tract, it contracts (closes) or relaxes (opens) at our will. Contraction will stop a bowel movement while relaxation allows stool to pass out of the body.

3. Sites for absorption of nutrients
9 litres of fluid pass through the duodenum each day of which only 1.5L reaches the colon
stomach
duodenum
jejunum
ileum
Ascending colon
minerals
Water sol vits
sugars
Vits A & D
Bile salts
Water, sodium,
potassium, vits
Fats
Vit B12
Water & sodium
Amino acids

4. Why is the Intestine important?
‘The intestinal tract contains the body's largest interface between a person and his or her external environment’. [Farhedi 2003]
It acts as:
a filter which allows selected nutrients to pass through
a barrier to prevent the penetration of harmful microorganisms & chemicals
Small Intestine: nutrients from food are digested and absorbed here as food is moved through by peristalsis.
Large Intestine: absorbs water and electrolytes, (sodium, calcium, and potassium). Home for bacteria…
Filter; it allows movement of nutrients from the intestinal lumen into the circulation.
Barrier; keeps out luminal ‘nasties’

5. liver

6. Low residue diet
Doctors often have their patients follow a low-residue diet the first weeks after any abdominal surgery.
This includes only foods that are easily digested and don't leave much waste behind,
When going back to foods you have not eaten since surgery, try one new food a day. Keep a food and symptom log. 
if they seem to cause symptoms, try them again in 2-3 weeks.  Record results.  Eventually you should be able to have a full and varied diet. 

7. Reintroducing foods…
‘It took about 6 mos for me to eat fresh fruits and vegetables without them speeding through my system.  It takes time for the body to slow down.  Some foods work better than others, peanut butter made me worse as did applesauce, however others have had great results with them.  Keep a food log.  Try new foods, if they don't work, try them again in 2-3 weeks.  Log results.  Eventually you should be able to have a full and varied diet.  I live on fresh fruits and vegetables now but it took a while to achieve this.  As for weight loss you can try bulking up by using powders or drinking high calorie shake drinks.  They make them dairy-free so you should be able to tolerate them’.
‘I had the reversal ileostomy 10 weeks ago just like Cathy and I eat everything’.
‘Certain foods like salad and chinese do go through a bit quicker, and curry and chilli do cause some bottom burning for a day or so, but I still eat them. I take 10ml of immodium syrup before bed but thats all’.

8. Foods and drinks that may cause loose stools:
May be caused by;
Very large meals
Spicy meals
Soup
chocolate, liqourice,
Drinks:
apple juice, prune juice
Red wine
beer
milk
Tea & coffee
Vegetables & Fruit
baked beans, Dried beans
green beans
spinach
cabbage
broccoli
raw fruit

9. Relieving diarrhoea May be helped by: Apple sauce
Peanut butter (smooth)
Bananas
Rice / pasta / potatoes
Tapioca
marshmallows, pretzels
jelly
Boiled milk, eggs
Drink plenty; bouillon, ginger ale, Weak tea
Depends how high up the stoma is (the higher up the more watery the stools)
Loose stools can also be caused by antibiotics, dodgy water (abroad), stress
University of pittsburgh medical centre 9

10. Wind Eat regularly; missing meals can use gas build up
Avoid swallowing air; relax, take your time and don’t talk with
your mouth full
Avoid chewing gum or drinking through a straw
Add cranberry juice, yogurt, and buttermilk.

11. Foods that may cause gas and odour:
Alcohol; beer
carbonated or caffiene beverages
Sorbitol
Eggs; meringues
fish
strong flavored cheeses
spiced foods
fatty foods (pastries/deep fried foods)
Melons, apricots, banana
asparagus
cabbage family , brussels, broccoli
cauliflower
dried beans and peas , baked beans
Radishes, onions, Cucumbers
pickles
mustard
Milk, nuts
These should be tried again at intervals: buttermilk, parsley and yogurt may reduce the odour
buttermilk, parsley and yogurt may reduce the odour

12. Relieving constipation
Increase liquids
Eat high fibre foods; fruit (chew well), veg – raw & cooked,
Wholemeal breads and cereals (oatmeal, wheat flakes, branflakes)
Coffee, chocolate, lemon juice, liqourice, prune juice
Exercise

13. FOODS WHICH MAY CONTRIBUTE TO ANAL IRRITATION
•  certain raw fruits and vegetables (e.g., oranges, apples, coleslaw, celery and corn)
•  popcorn
•  Chinese/oriental vegetables
•  nuts
•  coconut
•  dried fruits (e.g. raisins, figs)
•  food with seeds
•  spicy foods
Once again you will find that diet and food tolerances are very individual. The lists above are not meant to make your diet selections a chore, rather to assist you in modifying your selections should you encounter some difficulties. Patience is a virtue during the early weeks following your second surgery. Keep in mind though that you are well on your way to good nutrition and healthy lifestyle.
References:
1.) Hurd, Linda. Presenting a patients guide to ileoanal reservoir procedure. Ostomy/
Wound Management 1992; 38(5)2-60.

14. Probiotics: protective bacteria
Definitions;
Live micro-organisms which when administered in adequate amounts confer health benefits on the host (WHO / FAO 2002)
They must remain viable during their passage through the gut
Usually representative of species present in infants; Lactobacillus, Bifidobacterium, yeast Saccharomyces boulardii
Safe; by virtue of their long use in fermented diary products
Prospective long term studies show safe use in critically ill children, pre term neonates, immuno compromised patients with HIV
commensal microflora have a symbiotic relation with the host
They inhabit the whole gut with the largest amount in the lower GIT; mostly anaerobic
Competitive exclusion of pathogens

15. Protective bacteria
Ferment dietary fibres & complex starches in food in the colon resulting in:
short chain fatty acids; increase sodium, potassium uptake in the large intestine
energy provider for colon cells
Can produce gases (the down side!),
also some vitamins B12, K
may alleviate symptoms of lactose (milk sugar) intolerance
Reduce inflammation
Improve Bile salt metabolism; these may have an irritant effect on the bowel
Probiotics associated with decreased reduction in rate of progression of colon cancer in some small studies
Impaired butyric acid prodn linked to Crohns disease

16. How to achieve a Balanced Diet
STARCHY FOODS
e.g. bread, rice, potatoes, pasta, cereals
FRUIT AND VEGETABLES
MEAT, FISH, EGGS, BEANS
i.e. protein containing foods
MILK AND DAIRY FOODS
e.g. cheese, yoghurt, fromage frais
This plate, known as the Eatwell plate, demonstrates how to achieve a healthy balanced diet. As you can see the two biggest sections are Fruit and Vegetables, and bread, rice, potatoes and pasta, each contributing a third to the plate. The meat, fish, eggs and beans section and milk and dairy foods contribute smaller amounts to the plate. Some of you may be disappointed to see that foods high in fat and sugar take up the smallest section on the plate.
In addition to the plate you should ensure you do not consume more than 6g per day. Salt is found mainly in processed and pre-prepared foods so try to avoid too many of these and minimise the amount of salt you add at the table.
Fluid intake is also crucial to a healthy diet and you should aim for about 1.5 to 2 litres a day
We’re now going to go into each section of the plate in more detail.....
FOOD/DRINK HIGH IN FAT AND/OR SUGAR
aim to have less than 6g of salt per day
Aim to consume around 2 litres of fluid a day 16

17. Eatwell plate
This plate, demonstrates how to achieve a healthy balanced diet. As you can see the two biggest sections are Fruit and Vegetables, and bread, rice, potatoes and pasta, each contributing a third to the plate. The meat, fish, eggs and beans section and milk and dairy foods contribute smaller amounts to the plate.
Some of you may be disappointed to see that foods high in fat and sugar take up the smallest section on the plate!!
In addition to the plate you should ensure you do not consume more than 6g per day. Salt is found mainly in processed and pre-prepared foods so try to avoid too many of these and minimise the amount of salt you add at the table.
Fluid intake is also crucial to a healthy diet and you should aim for about 1.5 to 2 litres a day

18. Summary
Eat a balanced varied diet. i.e. food choices from all food groups
Eat slowly and chew your food well.
Drink plenty of fluids each day. (i.e. ~ 8 cups of fluid per day)
Add foods to your diet gradually to see how your body responds.
Any queries you can me