Short bowel syndrome

Step 1 – Loperamide and a PPI.

Loperamide may be initiated on specialist advice for reduction in stoma output (high output stomas). Capsules are the preferred loperamide formulation. They may be opened and contents dispersed in water prior to administration.

PPI – Omeprazole or lansoprazole.

Step 2 – if no improvement with optimised loperamide, dietary advice, PPI and fluid restriction – add in codeine (unless contra-indicated).

Step 3 – if no improvement with optimised loperamide, PPI, dietary advice, fluid restriction and codeine – refer to gastroenterology for review and consider octreotide (initiated only on advice of specialist consultant).

Prescribing Notes:

Non-pharmacological interventions to reduce stoma output include restricting fluid intake, increasing salt intake & reducing fibre intake.
Ispaghula husk may be used for regulation of bowel contents for patients with stoma and for intestinal dysmotility in GI disorders.
Perform baseline ECG for loperamide doses greater than 4mg four times daily. Repeat in 3 years if patient remains on high doses. Consider loperamide toxicity in any patient with fainting episodes not accounted for by dehydration or other drugs.
Octreotide may be considered for use on the advice of a specialist consultant in high output stoma and enterocutaneous fistula to reduce output when other means have failed. Octreotide is usually given as a short course of treatment for hospital in-patients. A small group of patients will require a longer course of octreotide continuing after hospital discharge with treatment remaining under the supervision of the specialist clinical team.

History Notes

15/04/2026

Regional formulary chapter launched.