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-2.5738 -.8497 -2.5738 c -.6786 -2.5738 -.5503 -2.5522 -.4279 -2.5161 c -.4646 -3.0554 l -.6419 -3.0985 -.8557 -3.1273 -1.033 -3.1273 c -1.6565 -3.1273 -1.8154 -2.7821 -1.6871 -1.9698 c -1.3632 0 l -1.9805 0 l -1.8949 .5034 l -1.2838 .5034 l -1.0941 1.6609 l -.5257 1.8116 l -.7397 .5034 l .0855 .5034 l 0 0 l f Q q 1 0 0 1 564.672 748.929 cm 0 0 m -.5624 .1866 -1.1615 -1.2151 -1.3204 -2.2071 c -1.4487 -3.0125 l -1.9867 -3.0125 l -1.412 .5607 l -.8865 .5607 l -.9354 .2513 -1.0209 -.1296 -1.1982 -.755 c -1.1859 -.762 l -.8436 .1075 -.4769 .7403 .1099 .6254 c 0 0 l f Q q 1 0 0 1 565.808 750.079 cm 0 0 m -.2018 0 -.3484 .1872 -.3361 .4099 c -.33 .6542 -.1527 .8413 .049 .8413 c .2444 .8413 .3973 .6616 .3853 .4388 c .3729 .1942 .1956 0 0 0 c h -.4523 -4.1625 m -.9901 -4.1625 l -.4095 -.5894 l .1284 -.5894 l -.4523 -4.1625 l f Q q 1 0 0 1 568.351 748.986 cm 0 0 m -.8252 0 l -1.1245 -1.8693 l -1.2104 -2.4226 -1.1491 -2.5738 -.8496 -2.5738 c -.6785 -2.5738 -.55 -2.5522 -.428 -2.5161 c -.4645 -3.0554 l -.642 -3.0985 -.8558 -3.1273 -1.033 -3.1273 c -1.6564 -3.1273 -1.8154 -2.7821 -1.6871 -1.9698 c -1.3629 0 l -1.9806 0 l -1.8949 .5034 l -1.2834 .5034 l -1.0941 1.6609 l -.5256 1.8116 l -.7394 .5034 l .0856 .5034 l 0 0 l f Q q 1 0 0 1 569.585 750.079 cm 0 0 m -.2015 0 -.3484 .1872 -.3359 .4099 c -.33 .6542 -.1525 .8413 .049 .8413 c .2446 .8413 .3973 .6616 .3851 .4388 c .3729 .1942 .1956 0 0 0 c h -.4521 -4.1625 m -.9901 -4.1625 l -.4095 -.5894 l .1287 -.5894 l -.4521 -4.1625 l f Q q 1 0 0 1 571.817 749.008 cm 0 0 m -.6663 0 -1.1127 -.8774 -1.1127 -1.7758 c -1.1127 -2.3079 -.9291 -2.6026 -.4708 -2.6026 c .1222 -2.6026 .6417 -1.8549 .6417 -.8127 c .6417 -.2878 .4401 0 0 0 c h -.5624 -3.1562 m -1.3263 -3.1562 -1.6749 -2.7034 -1.6749 -1.8837 c -1.6749 -.4601 -.9047 .5463 .0853 .5463 c .8863 .5463 1.2164 .0144 1.2164 -.7406 c 1.2164 -2.2145 .3544 -3.1562 -.5624 -3.1562 c f Q q 1 0 0 1 575.869 745.917 cm 0 0 m -.5378 0 l -.165 2.2862 l -.0732 2.8469 -.1588 3.0916 -.4341 3.0916 c -.9963 3.0916 -1.6198 1.6894 -1.7602 .8054 c -1.8887 0 l -2.4266 0 l -2.121 1.8693 l -2.0416 2.3797 -1.9315 3.0484 -1.852 3.5732 c -1.3203 3.5732 l -1.3569 3.3359 -1.4425 2.926 -1.6565 2.164 c -1.6442 2.164 l -1.3569 2.919 -.874 3.6448 -.2383 3.6448 c .324 3.6448 .5135 3.1777 .3973 2.4301 c 0 0 l f Q q 1 0 0 1 578.68 749.037 cm 0 0 m -.9047 0 -1.2591 -1.0998 -1.2591 -1.9843 c -1.2591 -2.4514 -1.137 -2.6384 -.9474 -2.6384 c -.373 -2.6384 .2505 -1.2076 .3911 -.3522 c .4339 -.0645 l .3116 -.0284 .1711 0 0 0 c h .4828 -3.12 m -.0611 -3.12 l -.006 -2.8109 .1099 -2.3363 .2935 -1.6678 c .2812 -1.6604 l .0611 -2.2141 -.3974 -3.192 -1.137 -3.192 c -1.577 -3.192 -1.8154 -2.8613 -1.8154 -2.1061 c -1.8154 -.7904 -1.2349 .5109 .0916 .5109 c .4401 .5109 .7641 .4675 1.045 .4028 c .7211 -1.5958 .6111 -2.2643 .4828 -3.12 c f Q q 1 0 0 1 580.709 745.917 cm 0 0 m -.5378 0 l .3118 5.2485 l .8498 5.2485 l 0 0 l f Q q 1 0 0 1 585.305 748.879 cm 0 0 m -.1652 .0865 -.3425 .1367 -.5563 .1367 c -1.3265 .1367 -1.6874 -.8841 -1.6874 -1.6964 c -1.6874 -2.0705 -1.5834 -2.4516 -1.0515 -2.4516 c -.8131 -2.4516 -.5563 -2.3869 -.3669 -2.2788 c -.4034 -2.8469 l -.6174 -2.9406 -.8988 -3.0195 -1.2045 -3.0195 c -1.9929 -3.0195 -2.2618 -2.5161 -2.2618 -1.8406 c -2.2618 -.4742 -1.6078 .6689 -.5198 .6689 c -.269 .6689 -.0674 .6255 .1221 .5609 c 0 0 l f Q q 1 0 0 1 587.371 749.037 cm 0 0 m -.9047 0 -1.259 -1.0998 -1.259 -1.9843 c -1.259 -2.4514 -1.1368 -2.6384 -.9473 -2.6384 c -.3728 -2.6384 .2507 -1.2076 .3914 -.3522 c .4339 -.0645 l .3119 -.0284 .1713 0 0 0 c h .4829 -3.12 m -.0611 -3.12 l -.006 -2.8109 .1101 -2.3363 .2935 -1.6678 c .2814 -1.6604 l .0613 -2.2141 -.3972 -3.192 -1.1368 -3.192 c -1.5768 -3.192 -1.8152 -2.8613 -1.8152 -2.1061 c -1.8152 -.7904 -1.2347 .5109 .0918 .5109 c .4403 .5109 .7643 .4675 1.0453 .4028 c .7213 -1.5958 .6115 -2.2643 .4829 -3.12 c f Q q 1 0 0 1 590.849 748.929 cm 0 0 m -.5622 .1866 -1.1611 -1.2151 -1.3203 -2.2071 c -1.4485 -3.0125 l -1.9865 -3.0125 l -1.4118 .5607 l -.8862 .5607 l -.9352 .2513 -1.0207 -.1296 -1.198 -.755 c -1.1857 -.762 l -.8434 .1075 -.4767 .7403 .1101 .6254 c 0 0 l f Q q 1 0 0 1 592.597 749.066 cm 0 0 m -.483 0 -.8069 -.496 -.9474 -1.0999 c -.006 -1.0566 .4097 -.8337 .4097 -.4025 c .4097 -.1438 .2447 0 0 0 c h -1.0148 -1.5743 m -1.033 -1.6824 -1.0453 -1.8619 -1.0453 -1.9913 c -1.0453 -2.5448 -.8803 -2.6887 -.3913 -2.6887 c -.1039 -2.6887 .2017 -2.6096 .4645 -2.4803 c .4645 -2.998 l .1712 -3.1345 -.1834 -3.2136 -.5807 -3.2136 c -1.2775 -3.2136 -1.6014 -2.8612 -1.6014 -2.0559 c -1.6014 -.6685 -.9474 .489 .0611 .489 c .7092 .489 .9537 .1009 .9537 -.3234 c .9537 -1.0929 .2872 -1.5168 -1.0148 -1.5743 c f Q EMC /Artifact <>BDC q 14.173 884.409 623.622 -870.236 re 325.98 449.31 m W n 0 898.59 651.96 -898.59 re W n 1 .89 0 0 k q 1 0 0 1 327.88 594.79 cm 0 0 m 257.014 0 l 258.58 0 259.849 -1.2693 259.849 -2.835 c 259.849 -127.559 l 259.849 -129.125 258.58 -130.394 257.014 -130.394 c -257.014 -130.394 l -258.58 -130.394 -259.849 -129.125 -259.849 -127.559 c -259.849 -2.835 l -259.849 -1.2693 -258.58 0 -257.014 0 c h f* Q EMC /P <>BDC BT /TT4 1 Tf 11 0 0 11 90.3469 565.3371 Tm 0 0 0 0 k 0 Tc .0099 Tw [(A)55.2( high output stoma \(HOS\) is when the stoma output causes the patient to become water)55.2(, sodium)]TJ ET EMC /P <>BDC BT 11 0 0 11 566.5677 565.3371 Tm 0 Tw ( )Tj ET EMC /P <>BDC BT 11 0 0 11 90.3469 549.337 Tm .0117 Tw [(and magnesium depleted. )18.1(This tends to occur when the output is more than 2 L)37.1( / 24 hours though)]TJ ET EMC /P <>BDC BT 11 0 0 11 566.5681 549.337 Tm 0 Tw ( )Tj ET EMC /P <>BDC BT 11 0 0 11 90.3469 533.3371 Tm .0152 Tw [(this varies according to the amount of food/drink taken orally \(if 4 L)37.1( is consumed a 2 L)37.1( output may)]TJ ET EMC /P <>BDC BT 11 0 0 11 566.568 533.3371 Tm 0 Tw ( )Tj ET EMC /P <>BDC BT 11 0 0 11 90.3469 517.3371 Tm -.0091 Tw [(not be a problem but if only 0.5 L)37.1( is consumed dehydration will follow\). )18(This occurs at some time in)]TJ ET EMC /P <>BDC BT 11 0 0 11 566.5677 517.3371 Tm 0 Tw ( )Tj ET EMC /P <>BDC BT 11 0 0 11 90.3469 501.3371 Tm -.0225 Tw (up to 30% of small bowel stomas. It rarely occurs if there is more than half of the colon in continuity)Tj ET EMC /P <>BDC BT 11 0 0 11 566.5685 501.3371 Tm 0 Tw ( )Tj ET EMC /P <>BDC BT 11 0 0 11 90.3469 485.3371 Tm (with the small intestine.)Tj ET EMC /P <>BDC BT /TT6 1 Tf 12 0 0 12 68.0312 448.4841 Tm 1 .89 0 0 k (Key points)Tj ET EMC /P <>BDC BT /TT4 1 Tf 8 0 0 8 129.373 448.4841 Tm 0 0 0 .8 k ( )Tj ET EMC /P <>BDC BT 8 0 0 8 68.0312 430.8348 Tm (1.)Tj ET EMC /P <>BDC BT 8 0 0 8 77.147 430.8348 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 79.3696 430.8348 Tm (Ensure good skin protection/bag fitting.)Tj ET EMC /P <>BDC BT 8 0 0 8 217.6783 430.8348 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 68.0312 418.8548 Tm (2.)Tj ET EMC /P <>BDC BT 8 0 0 8 77.147 418.8548 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 79.3696 418.8548 Tm (Exclude causes other than a short bowel \(e.g. obstruction\).)Tj ET EMC /P <>BDC BT 8 0 0 8 287.9282 418.8548 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 68.0312 406.8748 Tm (3. )Tj ET EMC /P <>BDC BT 8 0 0 8 77.147 406.8748 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 79.3696 406.8748 Tm (Rehydrate and stop thirst.)Tj ET EMC /P <>BDC BT 8 0 0 8 170.9751 406.8748 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 68.0312 394.8948 Tm (4. )Tj ET EMC /P <>BDC BT 8 0 0 8 77.147 394.8948 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 79.3696 394.8948 Tm (Restrict oral hypotonic fluid.)Tj ET EMC /P <>BDC BT 8 0 0 8 177.6352 394.8948 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 68.0312 382.9148 Tm (5. )Tj ET EMC /P <>BDC BT 8 0 0 8 77.147 382.9148 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 79.3696 382.9148 Tm (Sip a glucose/salt solution +/- magnesium supplements.)Tj ET EMC /P <>BDC BT 8 0 0 8 277.0298 382.9148 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 68.0312 370.9348 Tm (6. )Tj ET EMC /P <>BDC BT 8 0 0 8 77.147 370.9348 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 79.3696 370.9348 Tm (Commence loperamide \(high dose\) before food.)Tj ET EMC /P <>BDC BT 8 0 0 8 249.2407 370.9348 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 68.0312 358.9548 Tm (7. )Tj ET EMC /P <>BDC BT 8 0 0 8 77.147 358.9548 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 79.3696 358.9548 Tm (Commence a proton pump inhibitor \(especially if a net secretory )Tj ET EMC /P <>BDC BT 8 0 0 8 77.147 346.9748 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 79.3696 346.9748 Tm (output\).)Tj ET EMC /P <>BDC BT 8 0 0 8 108.2759 346.9748 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 68.0312 334.9947 Tm (8.)Tj ET EMC /P <>BDC BT 8 0 0 8 77.147 334.9947 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 79.3696 334.9947 Tm (Consider reducing oral insoluble fibre intake. )Tj ET EMC /P <>BDC BT 8 0 0 8 239.4595 334.9947 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 68.0312 323.0148 Tm (9. )Tj ET EMC /P <>BDC BT 8 0 0 8 77.147 323.0148 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 79.3696 323.0148 Tm (Consider subcutaneous fluid before resorting to parenteral fluids.)Tj ET EMC /P <>BDC BT 8 0 0 8 308.8384 323.0148 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 68.0312 311.0348 Tm -.085 Tc (10.)Tj ET EMC /P <>BDC BT 8 0 0 8 77.2269 311.0348 Tm 0 Tc ( )Tj ET EMC /P <>BDC BT 8 0 0 8 79.3696 311.0348 Tm -.01 Tc (Monitor random urinary sodium concentration and serum magnesium.)Tj ET EMC /P <>BDC BT 8 0 0 8 321.0337 311.0348 Tm 0 Tc ( )Tj ET EMC /P <>BDC BT 8 0 0 8 68.0312 299.0547 Tm -.1592 Tc [(11)-74.2(.)]TJ ET EMC /P <>BDC BT 8 0 0 8 77.147 299.0547 Tm 0 Tc ( )Tj ET EMC /P <>BDC BT 8 0 0 8 79.3696 299.0547 Tm (If an oral/enteral supplement is needed due to malnutrition, )Tj ET EMC /P <>BDC BT 8 0 0 8 77.147 287.0748 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 79.3696 287.0748 Tm [(the osmolarity aims to be near to 300 mOsm/L)37.1( and the sodium )]TJ ET EMC /P <>BDC BT 8 0 0 8 77.147 275.0948 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 79.3696 275.0948 Tm (concentration 100-140 mmol/L.)Tj ET EMC /P <>BDC BT 8 0 0 8 189.6548 275.0948 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 68.0312 263.1148 Tm -.085 Tc (12.)Tj ET EMC /P <>BDC BT 8 0 0 8 77.147 263.1148 Tm 0 Tc ( )Tj ET EMC /P <>BDC BT 8 0 0 8 79.3696 263.1148 Tm (Patients who need admission for rehydration should not just be )Tj ET EMC /P <>BDC BT 8 0 0 8 77.147 251.1349 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 79.3696 251.1349 Tm (rehydrated and discharged.)Tj ET EMC /P <>BDC BT 8 0 0 8 176.7681 251.1349 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 68.0312 239.1549 Tm -.085 Tc (13.)Tj ET EMC /P <>BDC BT 8 0 0 8 77.147 239.1549 Tm 0 Tc ( )Tj ET EMC /P <>BDC BT 8 0 0 8 79.3696 239.1549 Tm (Patients with a short bowel \(less than 2 m remaining\) needing )Tj ET EMC /P <>BDC BT 8 0 0 8 77.147 227.1748 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 79.3696 227.1748 Tm (parenteral support may be considered for a glucagon-like peptide-2 )Tj ET EMC /P <>BDC BT 8 0 0 8 77.147 215.1948 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 79.3696 215.1948 Tm (analogue. )Tj ET EMC /P <>BDC BT 8 0 0 8 116.7368 215.1948 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 68.0312 203.1948 Tm ( )Tj ET EMC /P <>BDC BT /TT6 1 Tf 12 0 0 12 68.0312 191.1948 Tm 1 .89 0 0 k (Explanations)Tj ET EMC /P <>BDC BT /TT4 1 Tf 8 0 0 8 142.7146 191.1948 Tm 0 0 0 .8 k ( )Tj ET EMC /P <>BDC BT 8 0 0 8 68.0312 174.0255 Tm (1.)Tj ET EMC /P <>BDC BT /TT6 1 Tf 8 0 0 8 77.147 174.0255 Tm ( )Tj ET EMC /P <>BDC BT /TT4 1 Tf 8 0 0 8 79.3696 174.0255 Tm [(A)55.2( high stoma output can cause a stoma bag to become detached )]TJ ET EMC /P <>BDC BT 8 0 0 8 77.147 162.5255 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 79.3696 162.5255 Tm (causing sore peri-stomal skin. )Tj ET EMC /P <>BDC BT 8 0 0 8 187.4126 162.5255 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 68.0312 145.3563 Tm (2. )Tj ET EMC /P <>BDC BT 8 0 0 8 77.147 145.3563 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 79.3696 145.3563 Tm (While a short bowel \(less than 200 cm jejunum remaining\) is the )Tj ET EMC /P <>BDC BT 8 0 0 8 77.147 133.8563 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 79.3696 133.8563 Tm (most common reason for a HOS \(occurring more than 3 weeks after)Tj ET EMC /P <>BDC BT 8 0 0 8 319.9087 133.8563 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 77.147 122.3562 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 79.3696 122.3562 Tm -.015 Tc (formation\), other easily treatable causes should be sought. Intermittent)Tj ET EMC /P <>BDC BT 8 0 0 8 320.644 122.3562 Tm 0 Tc ( )Tj ET EMC /P <>BDC BT 8 0 0 8 77.147 110.8563 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 79.3696 110.8563 Tm [(or partial obstruction is common. )55.2(A)55.2( history of sudden onset colicky )]TJ ET EMC /P <>BDC BT 8 0 0 8 77.147 99.3563 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 79.3696 99.3563 Tm -.015 Tc (abdominal pain, borborygmi, swelling/visible peristalsis and temporary)Tj ET EMC /P <>BDC BT 8 0 0 8 318.6418 99.3563 Tm 0 Tc ( )Tj ET EMC /P <>BDC BT 8 0 0 8 77.147 87.8562 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 79.3696 87.8562 Tm [(stopping of the stoma are suggestive. )18.1(The HOS tends to occur as )]TJ ET EMC /P <>BDC BT 8 0 0 8 77.147 76.3563 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 79.3696 76.3563 Tm -.015 Tc [(the obstruction resolves. )55.2(A)55.2( stenosis at or near to the stoma is common)]TJ ET EMC /P <>BDC BT 8 0 0 8 319.5365 76.3563 Tm 0 Tc ( )Tj ET EMC /P <>BDC BT 8 0 0 8 342.3382 451.3962 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 344.5608 451.3962 Tm (and may be detected by visual inspection or inserting a finger into )Tj ET EMC /P <>BDC BT 8 0 0 8 342.3382 439.8962 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 344.5608 439.8962 Tm [(the stoma. )55.2(A)55.2( low fibre diet may help, but often a surgical resection)]TJ ET EMC /P <>BDC BT 8 0 0 8 342.3382 428.3962 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 344.5608 428.3962 Tm (is )Tj ET EMC /P <>BDC BT 8 0 0 8 353.0647 428.3962 Tm (needed. Other causes include opioid or steroid withdrawal or the )Tj ET EMC /P <>BDC BT 8 0 0 8 342.3382 416.8962 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 344.5608 416.8962 Tm (giving of prokinetic drugs \(e.g. metoclopramide\). In the perioperative)Tj ET EMC /P <>BDC BT 8 0 0 8 586.0178 416.8962 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 342.3782 405.3962 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 344.5608 405.3962 Tm -.005 Tc (period \(less than 3 weeks after formation\) and especially if the output)Tj ET EMC /P <>BDC BT 8 0 0 8 585.8552 405.3962 Tm 0 Tc ( )Tj ET EMC /P <>BDC BT 8 0 0 8 342.3382 393.8962 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 344.5608 393.8962 Tm -.015 Tc (has changed to becoming high, abdominal infection \(with low albumin,)Tj ET EMC /P <>BDC BT 8 0 0 8 584.5496 393.8962 Tm 0 Tc ( )Tj ET EMC /P <>BDC BT 8 0 0 8 342.3382 382.3962 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 344.5608 382.3962 Tm [(raised CRP)18.1( and neutrophils, and an ileus\) may be associated and )]TJ ET EMC /P <>BDC BT 8 0 0 8 342.3382 370.8962 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 344.5608 370.8962 Tm [(infection should be actively sought \(CT)18.1( abdomen\). Other causes )]TJ ET EMC /P <>BDC BT 8 0 0 8 342.3382 359.3962 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 344.5608 359.3962 Tm (include small bowel diverticula \(bacterial overgrowth\), an ischaemic )Tj ET EMC /P <>BDC BT 8 0 0 8 342.3382 347.8962 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 344.5608 347.8962 Tm (segment of small bowel \(often associated with hypoalbuminaemia\), )Tj ET EMC /P <>BDC BT 8 0 0 8 342.3382 336.3962 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 344.5608 336.3962 Tm [(recurrent bowel disease \(e.g. Crohn)18.1(s disease\), coeliac disease, )]TJ ET EMC /P <>BDC BT 8 0 0 8 342.3382 324.8962 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 344.5608 324.8962 Tm [(hyperthyroidism or clostridium dif)18.1(ficile infection.)]TJ ET EMC /P <>BDC BT 8 0 0 8 511.5882 324.8962 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 333.2223 307.6369 Tm (3. )Tj ET EMC /P <>BDC BT 8 0 0 8 342.3382 307.6369 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 344.5608 307.6369 Tm (Rehydrating and stopping thirst may be done acutely by giving )Tj ET EMC /P <>BDC BT 8 0 0 8 342.3382 296.0469 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 344.5608 296.0469 Tm -.02 Tc (intravenous saline \(e.g. 0.9% saline\), while taking little or no oral intake)Tj ET EMC /P <>BDC BT 8 0 0 8 583.649 296.0469 Tm 0 Tc ( )Tj ET EMC /P <>BDC BT 8 0 0 8 342.3382 284.4569 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 344.5608 284.4569 Tm -.005 Tc (\(be conscious to monitor and time limit so patients do not experience)Tj ET EMC /P <>BDC BT 8 0 0 8 585.0406 284.4569 Tm 0 Tc ( )Tj ET EMC /P <>BDC BT 8 0 0 8 342.3382 272.8669 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 344.5608 272.8669 Tm [(prolonged restrictions on oral intake\). )18.1(The sodium concentration of )]TJ ET EMC /P <>BDC BT 8 0 0 8 342.3382 261.2769 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 344.5608 261.2769 Tm (small bowel stomal fluid is always \(whatever the oral intake\) about )Tj ET EMC /P <>BDC BT 8 0 0 8 342.3382 249.6869 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 344.5608 249.6869 Tm (100 mmol/l \(range 80-140\). Daily weight and fluid balance charts )Tj ET EMC /P <>BDC BT 8 0 0 8 342.3382 238.0969 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 344.5608 238.0969 Tm (will help with monitoring; bag leaks may cause the losses to be )Tj ET EMC /P <>BDC BT 8 0 0 8 342.3382 226.5069 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 344.5608 226.5069 Tm (underestimated.)Tj ET EMC /P <>BDC BT 8 0 0 8 401.928 226.5069 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 333.2223 209.2375 Tm (4. )Tj ET EMC /P <>BDC BT 8 0 0 8 342.3382 209.2375 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 344.5608 209.2375 Tm [(Hypotonic fluid \(e.g. water\) causes a net ef)18.1(flux of sodium into the )]TJ ET EMC /P <>BDC BT 8 0 0 8 342.3382 197.6376 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 344.5608 197.6376 Tm -.005 Tc (bowel lumen and this is lost through the stoma. Patients must restrict)Tj ET EMC /P <>BDC BT 8 0 0 8 585.4304 197.6376 Tm 0 Tc ( )Tj ET EMC /P <>BDC BT 8 0 0 8 342.3382 186.0376 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 344.5608 186.0376 Tm [(oral hypotonic fluid \(e.g. to 0.5 1.0 L)37.1( / 24 hrs\). )18.1(They must not be )]TJ ET EMC /P <>BDC BT 8 0 0 8 342.3382 174.4376 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 344.5608 174.4376 Tm (told to drink as much as possible. In addition, they should not take)Tj ET EMC /P <>BDC BT 8 0 0 8 585.5842 174.4376 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 342.3382 162.8376 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 344.5608 162.8376 Tm (hypertonic fluid \(e.g. elemental diet\) as this will cause a net flow of )Tj ET EMC /P <>BDC BT 8 0 0 8 342.3382 151.2376 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 344.5608 151.2376 Tm (fluid into the bowel lumen \(together with sodium\) exacerbating water)Tj ET EMC /P <>BDC BT 8 0 0 8 586.0219 151.2376 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 342.3382 139.6375 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 344.5608 139.6375 Tm (and sodium depletion. )Tj ET EMC /P <>BDC BT 8 0 0 8 425.0608 139.6375 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 333.2223 122.4683 Tm (5. )Tj ET EMC /P <>BDC BT 8 0 0 8 342.3382 122.4683 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 344.5608 122.4683 Tm [(An oral rehydration solution is sipped \(e.g. St Mark)18.1(s modified WHO )]TJ ET EMC /P <>BDC BT 8 0 0 8 342.3382 110.9683 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 344.5608 110.9683 Tm -.02 Tc (cholera solution, double strength Dioralyte)Tj ET EMC /P <>BDC BT 4.8 0 0 4.8 487.1039 113.2932 Tm 0 Tc ()Tj ET EMC /P <>BDC BT 8 0 0 8 490.4806 110.9683 Tm -.02 Tc [(\) \(1 L)37.1( / 24 hrs\). )18.1(The glucose)]TJ ET EMC /P <>BDC BT 8 0 0 8 583.6656 110.9683 Tm 0 Tc ( )Tj ET EMC /P <>BDC BT 8 0 0 8 342.3382 99.4683 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 344.5608 99.4683 Tm (is absorbed with sodium. Rarely oral sodium chloride tablets may )Tj ET EMC /P <>BDC BT 8 0 0 8 342.3382 87.9683 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 344.5608 87.9683 Tm (be taken. Oral magnesium supplementation may be needed )Tj ET EMC /P <>BDC BT 8 0 0 8 342.3382 76.4683 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 344.5608 76.4683 Tm (but correcting sodium depletion alone may be adequate.)Tj ET EMC /P <>BDC BT 8 0 0 8 543.803 76.4683 Tm ( )Tj ET EMC /P <>BDC BT /TT6 1 Tf 9 0 0 9 51.0232 842.5103 Tm 1 .15 0 0 k [(THE BRITISH INTESTINAL)18.1( F)55.2(AILURE )37.1(ALLIANCE \(BIF)55.2(A\) T)18.1(O)0(P)18.1( TIPS )37.1(ARTICLE SERIES)]TJ ET EMC /Artifact <>BDC 0 0 0 .6 k 14.16 835.126 623.631 1.417 re f EMC /P <>BDC BT /TT4 1 Tf 8 0 0 8 51.0232 42.7031 Tm 0 0 0 0 k [(BIF)55.2(A)55.2( is a Specialist Interest Group of ϳԹ )]TJ ET EMC /P <>BDC BT /TT6 1 Tf 8 0 0 8 219.5466 42.7031 Tm [(www)37.1(.bapen.org.uk )]TJ ET EMC /P <>BDC BT /TT4 1 Tf 8 0 0 8 68.0312 603.432 Tm 0 0 0 .8 k [(Jeremy Nightingale and the BIF)55.2(A)55.2( Committee)]TJ ET EMC /P <>BDC BT 7 0 0 7 421.7818 43.4325 Tm 0 0 0 0 k [(Updated )55.2(April 2023. Review due )55.2(April 2026 | Page 1 of 2)]TJ ET EMC Q /Cs8 cs 0 scn 27.346 885.582 270.824 13.008 re f BT /TT2 1 Tf 8 0 0 8 31.346 889.5818 Tm 1 scn 0 Tc 0 Tw (BIFA Top Tips - High OP Stoma.qxp_Layout 1 03/05/2023 09:37 Page 1)Tj ET /Cs8 CS 0 SCN 0 J 0 j .65 w 10 M [] 0 d q 1 0 0 1 28.346 884.409 cm 0 0 m 0 14.173 l S 1 0 0 1 -14.173 -14.173 cm 0 0 m -14.173 0 l S 1 0 0 1 609.449 14.173 cm 0 0 m 0 14.173 l S 1 0 0 1 14.173 -14.173 cm 0 0 m 14.173 0 l S 1 0 0 1 -609.449 -856.063 cm 0 0 m 0 -14.173 l S 1 0 0 1 -14.173 14.173 cm 0 0 m -14.173 0 l S 1 0 0 1 609.449 -14.173 cm 0 0 m 0 -14.173 l S 1 0 0 1 14.173 14.173 cm 0 0 m 14.173 0 l S Q 1 SCN .25 w q 1 0 0 1 28.346 884.409 cm 0 0 m 0 14.173 l S 1 0 0 1 -14.173 -14.173 cm 0 0 m -14.173 0 l S 1 0 0 1 609.449 14.173 cm 0 0 m 0 14.173 l S 1 0 0 1 14.173 -14.173 cm 0 0 m 14.173 0 l S 1 0 0 1 -609.449 -856.063 cm 0 0 m 0 -14.173 l S 1 0 0 1 -14.173 14.173 cm 0 0 m -14.173 0 l S 1 0 0 1 609.449 -14.173 cm 0 0 m 0 -14.173 l S 1 0 0 1 14.173 14.173 cm 0 0 m 14.173 0 l S Q 0 SCN .65 w q 1 0 0 1 311.984 891.409 cm 0 0 m 28 0 l S 1 0 0 1 14 7 cm 0 0 m 0 -14 l S Q q 1 0 0 1 330.984 891.409 cm 0 0 m 0 -2.7615 -2.2386 -5 -5 -5 c -7.7614 -5 -10 -2.7615 -10 0 c -10 2.7614 -7.7614 5 -5 5 c -2.2386 5 0 2.7614 0 0 c s Q 0 scn q 1 0 0 1 329.184 891.409 cm 0 0 m 0 -1.7673 -1.4327 -3.2001 -3.2 -3.2001 c -4.9673 -3.2001 -6.4 -1.7673 -6.4 0 c -6.4 1.7673 -4.9673 3.2 -3.2 3.2 c -1.4327 3.2 0 1.7673 0 0 c f Q 1 SCN .25 w q 1 0 0 1 311.984 891.409 cm 0 0 m 28 0 l S 1 0 0 1 14 7 cm 0 0 m 0 -14 l S 1 0 0 1 5 -7 cm 0 0 m 0 -2.7615 -2.2386 -5 -5 -5 c -7.7614 -5 -10 -2.7615 -10 0 c -10 2.7614 -7.7614 5 -5 5 c -2.2386 5 0 2.7614 0 0 c s Q 1 scn q 1 0 0 1 328.984 891.409 cm 0 0 m 0 -1.6569 -1.3432 -3 -3 -3 c -4.6569 -3 -6 -1.6569 -6 0 c -6 1.6569 -4.6569 3 -3 3 c -1.3432 3 0 1.6569 0 0 c f Q 0 SCN .25 w q 1 0 0 1 328.176 893.601 cm 0 0 m -4.3841 -4.384 l S 1 0 0 1 -4.3841 0 cm 0 0 m 4.3841 -4.384 l S Q .65 w q 1 0 0 1 311.984 7.1728 cm 0 0 m 28 0 l S 1 0 0 1 14 7 cm 0 0 m 0 -14 l S 1 0 0 1 5 -7 cm 0 0 m 0 -2.7614 -2.2386 -5 -5 -5 c -7.7614 -5 -10 -2.7614 -10 0 c -10 2.7614 -7.7614 5 -5 5 c -2.2386 5 0 2.7614 0 0 c s Q 0 scn q 1 0 0 1 329.184 7.1728 cm 0 0 m 0 -1.7673 -1.4327 -3.2 -3.2 -3.2 c -4.9673 -3.2 -6.4 -1.7673 -6.4 0 c -6.4 1.7673 -4.9673 3.2 -3.2 3.2 c -1.4327 3.2 0 1.7673 0 0 c f Q 1 SCN .25 w q 1 0 0 1 311.984 7.1728 cm 0 0 m 28 0 l S 1 0 0 1 14 7 cm 0 0 m 0 -14 l S 1 0 0 1 5 -7 cm 0 0 m 0 -2.7614 -2.2386 -5 -5 -5 c -7.7614 -5 -10 -2.7614 -10 0 c -10 2.7614 -7.7614 5 -5 5 c -2.2386 5 0 2.7614 0 0 c s Q 1 scn q 1 0 0 1 328.984 7.1728 cm 0 0 m 0 -1.6569 -1.3432 -3 -3 -3 c -4.6569 -3 -6 -1.6569 -6 0 c -6 1.6569 -4.6569 3 -3 3 c -1.3432 3 0 1.6569 0 0 c f Q 0 SCN .25 w q 1 0 0 1 328.176 9.3648 cm 0 0 m -4.3841 -4.384 l S 1 0 0 1 -4.3841 0 cm 0 0 m 4.3841 -4.384 l S Q .65 w q 1 0 0 1 7.173 463.291 cm 0 0 m 0 -28 l S 1 0 0 1 7 -14 cm 0 0 m -14 0 l S 1 0 0 1 -7 -5 cm 0 0 m -2.7614 0 -5 2.2386 -5 5 c -5 7.7614 -2.7614 10 0 10 c 2.7614 10 5 7.7614 5 5 c 5 2.2386 2.7614 0 0 0 c s Q 0 scn q 1 0 0 1 7.173 446.091 cm 0 0 m -1.7673 0 -3.2 1.4327 -3.2 3.2 c -3.2 4.9673 -1.7673 6.4 0 6.4 c 1.7673 6.4 3.2 4.9673 3.2 3.2 c 3.2 1.4327 1.7673 0 0 0 c f Q 1 SCN .25 w q 1 0 0 1 7.173 463.291 cm 0 0 m 0 -28 l S 1 0 0 1 7 -14 cm 0 0 m -14 0 l S 1 0 0 1 -7 -5 cm 0 0 m -2.7614 0 -5 2.2386 -5 5 c -5 7.7614 -2.7614 10 0 10 c 2.7614 10 5 7.7614 5 5 c 5 2.2386 2.7614 0 0 0 c s Q 1 scn q 1 0 0 1 7.173 446.291 cm 0 0 m -1.6568 0 -3 1.3431 -3 3 c -3 4.6569 -1.6568 6 0 6 c 1.6569 6 3 4.6569 3 3 c 3 1.3431 1.6569 0 0 0 c f Q 0 SCN .25 w q 1 0 0 1 9.365 447.099 cm 0 0 m -4.3841 4.3841 l S 1 0 0 1 0 4.3841 cm 0 0 m -4.3841 -4.3841 l S Q .65 w q 1 0 0 1 644.795 463.291 cm 0 0 m 0 -28 l S 1 0 0 1 6.9999 -14 cm 0 0 m -14 0 l S 1 0 0 1 -6.9999 -5 cm 0 0 m -2.7615 0 -5.0001 2.2386 -5.0001 5 c -5.0001 7.7614 -2.7615 10 0 10 c 2.7614 10 5 7.7614 5 5 c 5 2.2386 2.7614 0 0 0 c s Q 0 scn q 1 0 0 1 644.795 446.091 cm 0 0 m -1.7673 0 -3.2001 1.4327 -3.2001 3.2 c -3.2001 4.9673 -1.7673 6.4 0 6.4 c 1.7673 6.4 3.2 4.9673 3.2 3.2 c 3.2 1.4327 1.7673 0 0 0 c f Q 1 SCN .25 w q 1 0 0 1 644.795 463.291 cm 0 0 m 0 -28 l S 1 0 0 1 6.9999 -14 cm 0 0 m -14 0 l S 1 0 0 1 -6.9999 -5 cm 0 0 m -2.7615 0 -5.0001 2.2386 -5.0001 5 c -5.0001 7.7614 -2.7615 10 0 10 c 2.7614 10 5 7.7614 5 5 c 5 2.2386 2.7614 0 0 0 c s Q 1 scn q 1 0 0 1 644.795 446.291 cm 0 0 m -1.6569 0 -3 1.3431 -3 3 c -3 4.6569 -1.6569 6 0 6 c 1.6569 6 3 4.6569 3 3 c 3 1.3431 1.6569 0 0 0 c f Q 0 SCN .25 w q 1 0 0 1 646.987 447.099 cm 0 0 m -4.384 4.3841 l S 1 0 0 1 0 4.3841 cm 0 0 m -4.384 -4.3841 l S Q endstream endobj 79 0 obj <>/ExtGState<>/ColorSpace<>>> endobj 86 0 obj <>stream H6THHP(.M0f endstream endobj 84 0 obj [/Separation/All/DeviceGray 86 0 R] endobj 88 0 obj <> endobj 140 0 obj <>stream /Figure <>BDC q 1 i 12.346 823.182 625.344 -936.03 re 325.98 449.31 m W* n 14.173 884.409 623.622 -870.236 re 325.98 449.31 m W n 0 898.59 651.96 -898.59 re W n /GS2 gs q 732.37 110.716 -83.398 551.67 26.617 -79.272 cm /Im1 Do Q EMC /P <>BDC Q q 1 i 14.173 884.409 623.622 -870.236 re 325.98 449.31 m W n 0 898.59 651.96 -898.59 re W n /GS1 gs BT /TT6 1 Tf 9 0 0 9 51.0232 842.5116 Tm 1 .15 0 0 k 0 Tc 0 Tw [(THE BRITISH INTESTINAL)18.1( F)55.2(AILURE )37.1(ALLIANCE \(BIF)55.2(A\) T)18.1(O)0(P)18.1( TIPS )37.1(ARTICLE SERIES)]TJ ET EMC /Artifact <>BDC 0 0 0 .6 k 14.16 835.127 623.631 1.4169 re f EMC /Artifact <>BDC 1 .1 0 .1 k 14.16 15.774 619.472 44.054 re f EMC /P <>BDC BT /TT4 1 Tf 8 0 0 8 51.0232 42.7043 Tm 0 0 0 0 k [(BIF)55.2(A)55.2( is a Specialist Interest Group of ϳԹ )]TJ ET EMC /P <>BDC BT /TT6 1 Tf 8 0 0 8 219.5467 42.7043 Tm [(www)37.1(.bapen.org.uk )]TJ ET EMC /Artifact <>BDC 0 0 0 .08 k 67.346 250.777 520.424 199.316 re f EMC /P <>BDC BT 9 0 0 9 84.8161 427.9282 Tm 1 .89 0 0 k (Suggested reading:)Tj ET EMC /P <>BDC BT /TT4 1 Tf 8 0 0 8 192.8161 427.9282 Tm 0 0 0 .8 k ( )Tj ET EMC /P <>BDC BT 8 0 0 8 84.8161 413.0936 Tm ()Tj ET EMC /P <>BDC BT 8 0 0 8 93.32 413.0936 Tm (Nightingale JMD \(2021\). How to manage a high-output stoma. Frontline Gastroenterol.; 13\(2\): 140-151.)Tj ET EMC /P <>BDC BT 8 0 0 8 458.4021 413.0936 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 84.8161 401.0936 Tm ()Tj ET EMC /P <>BDC BT 8 0 0 8 93.32 401.0936 Tm [(British Intestinal Failure )55.2(Alliance \(BIF)55.2(A\) \(2018\). Position Statement: )18.1(The use of high dose loperamide in patients with intesti)]TJ 54.2319 0 TD (nal failure. )Tj ET EMC /P <>BDC BT 8 0 0 8 93.32 389.0936 Tm [(A)18.1(vailable online: www)55.2(.bapen.org.uk/pdfs/bifa/position-statements/use-of-loperamide-in-patients-with-intestinal-failure.pdf \(Mar)]TJ 55.5093 0 TD ( 2023\))Tj ET EMC /P <>BDC BT 8 0 0 8 560.0778 389.0936 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 84.8161 377.0936 Tm ()Tj ET EMC /P <>BDC BT 8 0 0 8 93.32 377.0936 Tm -.005 Tc [(British Intestinal Failure )55.2(Alliance \(BIF)55.2(A\) \(2018\). Position Statement: Use of peptide growth factors for adult patients with in)]TJ 53.0581 0 TD (testinal failure.)Tj ET EMC /P <>BDC BT 8 0 0 8 568.6882 377.0936 Tm 0 Tc ( )Tj ET EMC /P <>BDC BT 8 0 0 8 93.32 365.0936 Tm -.015 Tc [(A)18.1(vailable online: www)55.2(.bapen.org.uk/pdfs/bifa/position-statements/use-of-peptide-growth-factors-for-adult-patients-with-intestin)]TJ 53.6604 0 TD (al-failure.pdf)Tj ET EMC /P <>BDC BT 8 0 0 8 564.9475 365.0936 Tm 0 Tc ( )Tj ET EMC /P <>BDC BT 8 0 0 8 93.32 353.0936 Tm (\(Mar 2023\))Tj ET EMC /P <>BDC BT 8 0 0 8 132.445 353.0936 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 84.8161 341.0936 Tm ()Tj ET EMC /P <>BDC BT 8 0 0 8 93.32 341.0936 Tm [(British Intestinal Failure )55.2(Alliance \(BIF)55.2(A\) \(2022\). Managing Crohn)18.1(s Disease in Intestinal Failure. BIF)55.2(A)55.2( )18.1(T)110.8(op )18.1(T)37.1(ips )55.2(Article Series)]TJ 54.3774 0 TD -.0552 Tw [(. A)18.1(vailable )]TJ ET EMC /P <>BDC BT 8 0 0 8 93.32 329.0936 Tm 0 Tw [(online: www)55.2(.bapen.org.uk/pdfs/bifa/bifa-top-tips-series-20.pdf \(Mar 2023\))]TJ ET EMC /P <>BDC BT 8 0 0 8 351.6755 329.0936 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 84.8161 317.0936 Tm ()Tj ET EMC /P <>BDC BT 8 0 0 8 93.32 317.0936 Tm [(British Intestinal Failure )55.2(Alliance \(BIF)55.2(A\) \(2021\). Nutritional and fluid assessment of patients with intestinal failure. BIF)55.2(A)55.2( )18.1(T)]TJ 52.729 0 TD -.0181 Tw [(op T)37.1(ips )37.1(Article )]TJ ET EMC /P <>BDC BT 8 0 0 8 93.32 305.0936 Tm 0 Tw [(Series. )55.2(A)18.1(vailable online: www)55.2(.bapen.org.uk/pdfs/bifa/bifa-top-tips-series-16.pdf \(Mar 2023\))]TJ ET EMC /P <>BDC BT 8 0 0 8 412.8982 305.0936 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 84.8161 293.0936 Tm ()Tj ET EMC /P <>BDC BT 8 0 0 8 93.32 293.0936 Tm [(Mitchell )55.2(A, England C, Perry R, )]TJ ET EMC /P <>BDC BT /TT8 1 Tf 8 0 0 8 205.363 293.0936 Tm (et al.)Tj ET EMC /P <>BDC BT /TT4 1 Tf 8 0 0 8 222.7067 293.0936 Tm [( \(2021\). Dietary management for people with an ileostomy: a scoping review)55.2(. JBI evid synth.; )]TJ ET EMC /P <>BDC BT 8 0 0 8 93.32 281.0936 Tm (19\(9\): 2188-2306.)Tj ET EMC /P <>BDC BT 8 0 0 8 156.9216 281.0936 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 84.8161 269.0936 Tm ()Tj ET EMC /P <>BDC BT 8 0 0 8 93.32 269.0936 Tm [(NICE technology appraisal guidance [T)74.2(A804]. )18.1(T)110.8(eduglutide for treating short bowel syndrome. 30 June 2022.)]TJ ET EMC /P <>BDC BT 8 0 0 8 473.7029 269.0936 Tm ( )Tj ET EMC /P <>BDC BT /TT6 1 Tf 6 0 0 6 67.346 239.2041 Tm (Disclaimer:)Tj ET EMC /P <>BDC BT /TT4 1 Tf 6 0 0 6 99.6956 239.2041 Tm ( ϳԹ Position Statements/Guidelines have been prepared as guidance only to assist qualified healthcare professionals in the d)Tj 57.4793 0 TD (ecision-making processes surrounding )Tj ET EMC /P <>BDC BT 6 0 0 6 67.346 230.2041 Tm (nutritional care. Users of these materials may only do so on the condition that they exercise their own professional knowledge )Tj 55.6961 0 TD (and skills when applying such guidance to specific circumstances.)Tj ET EMC /P <>BDC BT 6 0 0 6 576.6135 230.2041 Tm ( )Tj ET EMC /P <>BDC BT 6 0 0 6 67.346 221.2041 Tm (Anyone without the appropriate qualifications must seek the advice of a qualified healthcare professional before taking, or ref)Tj 55.0887 0 TD (raining from, any action on the basis of the policies or guidance.)Tj ET EMC /P <>BDC BT 6 0 0 6 567.3118 221.2041 Tm ( )Tj ET EMC /P <>BDC BT 6 0 0 6 67.346 212.2041 Tm (ϳԹ does not \(i\) owe a duty of care to users of the policies, guidance or practice tips who are not qualified healthcare prof)Tj 55.1971 0 TD (essionals; and \(ii\) cannot accept liability to anyone using these )Tj ET EMC /P <>BDC BT 6 0 0 6 67.346 203.2041 Tm (policies, guidance or practice tips.)Tj ET EMC /P <>BDC BT 7 0 0 7 421.2284 43.4323 Tm 0 0 0 0 k [(Updated )55.2(April 2023. Review due )55.2(April 2026 | Page 2 of 2)]TJ ET EMC /P <>BDC BT 8 0 0 8 68.2207 810.4128 Tm 0 0 0 .8 k -.01 Tc (6. )Tj ET EMC /P <>BDC BT 8 0 0 8 77.4166 810.4128 Tm 0 Tc ( )Tj ET EMC /P <>BDC BT 8 0 0 8 79.5594 810.4128 Tm -.01 Tc (Loperamide up to 16 mg qds 30 - 60 minutes before food may reduce)Tj ET EMC /P <>BDC BT 8 0 0 8 320.2879 810.4128 Tm 0 Tc ( )Tj ET EMC /P <>BDC BT 8 0 0 8 77.3366 799.3127 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 79.5594 799.3127 Tm (transit and increase absorption. Care is needed with higher doses )Tj ET EMC /P <>BDC BT 8 0 0 8 77.3366 788.2128 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 79.5594 788.2128 Tm -.02 Tc (\(more than 4 mg four times a day\) due to possible cardiac arrhythmias.)Tj ET EMC /P <>BDC BT 8 0 0 8 319.1385 788.2128 Tm 0 Tc ( )Tj ET EMC /P <>BDC BT 8 0 0 8 77.3366 777.1128 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 79.5594 777.1128 Tm (The addition of codeine phosphate 30-60 mg four times a day may )Tj ET EMC /P <>BDC BT 8 0 0 8 77.3366 766.0128 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 79.5594 766.0128 Tm (further help and reduce output \(but does cause sedation and is )Tj ET EMC /P <>BDC BT 8 0 0 8 77.3366 754.9128 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 79.5594 754.9128 Tm (addictive\). If the stomal output increases with anti-diarrhoeal drugs, )Tj ET EMC /P <>BDC BT 8 0 0 8 77.3366 743.8127 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 79.5594 743.8127 Tm (consider a partial obstruction.)Tj ET EMC /P <>BDC BT 8 0 0 8 184.0593 743.8127 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 68.2207 727.0435 Tm -.015 Tc (7. )Tj ET EMC /P <>BDC BT 8 0 0 8 77.4566 727.0435 Tm 0 Tc ( )Tj ET EMC /P <>BDC BT 8 0 0 8 79.5594 727.0435 Tm [(A)55.2( proton pump inhibitor \(e.g. omeprazole 40 mg daily\), will reduce )]TJ ET EMC /P <>BDC BT 8 0 0 8 77.3366 715.9435 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 79.5594 715.9435 Tm [(output in net secretors)37.1( \(those whose output is greater than their )]TJ ET EMC /P <>BDC BT 8 0 0 8 77.3366 704.8435 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 79.5594 704.8435 Tm -.015 Tc [(oral intake\). )55.2(As proton pump inhibitors may cause hypomagnesaemia,)]TJ ET EMC /P <>BDC BT 8 0 0 8 318.8818 704.8435 Tm 0 Tc ( )Tj ET EMC /P <>BDC BT 8 0 0 8 77.3366 693.7435 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 79.5594 693.7435 Tm (osteoporosis and cardiac arrhythmias they should not be given )Tj ET EMC /P <>BDC BT 8 0 0 8 77.3366 682.6435 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 79.5594 682.6435 Tm [(routinely and certainly stopped if no ef)18.1(fect. )18.1(The dose of omeprazole )]TJ ET EMC /P <>BDC BT 8 0 0 8 77.3366 671.5435 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 79.5594 671.5435 Tm (can be titrated upwards so that the stomal pH exceeds 5. Octreotide)Tj ET EMC /P <>BDC BT 8 0 0 8 320.5788 671.5435 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 77.3366 660.4435 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 79.5594 660.4435 Tm (is rarely recommended due to a painful injection, gallstones and )Tj ET EMC /P <>BDC BT 8 0 0 8 77.3366 649.3435 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 79.5594 649.3435 Tm [(worry about its ef)18.1(fect in inhibiting )]TJ ET EMC /P <>BDC BT 8 0 0 8 197.696 649.3435 Tm -.005 Tc (bowel growth hormones. It is )Tj ET EMC /P <>BDC BT 8 0 0 8 77.3766 638.2434 Tm 0 Tc ( )Tj ET EMC /P <>BDC BT 8 0 0 8 79.5594 638.2434 Tm -.005 Tc (equivalent to omeprazole in the amount)Tj ET EMC /P <>BDC BT 8 0 0 8 218.1299 638.2434 Tm 0 Tc ( to which it reduces the )Tj ET EMC /P <>BDC BT 8 0 0 8 77.3366 627.1435 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 79.5594 627.1435 Tm (volume of stomal output in net secretors.)Tj ET EMC /P <>BDC BT 8 0 0 8 227.1843 627.1435 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 68.2207 610.3741 Tm (8.)Tj ET EMC /P <>BDC BT 8 0 0 8 77.3366 610.3741 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 79.5594 610.3741 Tm [(While insoluble fibre increases the rate of colonic transit, its ef)18.1(fect )]TJ ET EMC /P <>BDC BT 8 0 0 8 77.3366 599.2741 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 79.5594 599.2741 Tm [(on small bowel transit time is unclear)55.2(. It has been used to thicken )]TJ ET EMC /P <>BDC BT 8 0 0 8 77.3366 588.1741 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 79.5594 588.1741 Tm [(ileostomy output. However)55.2(, as is common, a small bowel stricture )]TJ ET EMC /P <>BDC BT 8 0 0 8 77.3366 577.0741 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 79.5594 577.0741 Tm (\(often due to adhesions\) may be present, and by causing partial )Tj ET EMC /P <>BDC BT 8 0 0 8 77.3366 565.9741 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 79.5594 565.9741 Tm (intestinal obstruction \(which can be painless\) it can increase the )Tj ET EMC /P <>BDC BT 8 0 0 8 77.3366 554.8741 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 79.5594 554.8741 Tm (stomal output; hence a low fibre intake is commonly recommended. )Tj ET EMC /P <>BDC BT 8 0 0 8 77.3366 543.7741 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 79.5594 543.7741 Tm (If patients are malnourished or there is concern about the nutritional)Tj ET EMC /P <>BDC BT 8 0 0 8 319.2546 543.7741 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 77.3366 532.6741 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 79.5594 532.6741 Tm (balance of their diet, they may benefit from referral to a dietitian )Tj ET EMC /P <>BDC BT 8 0 0 8 77.3366 521.5741 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 79.5594 521.5741 Tm (with expertise in gastroenterology and surgical nutrition for a more )Tj ET EMC /P <>BDC BT 8 0 0 8 77.3366 510.4741 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 79.5594 510.4741 Tm (thorough dietetic assessment and individualised advice. )Tj ET EMC /P <>BDC BT 8 0 0 8 279.235 510.4741 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 68.2207 493.7048 Tm (9. )Tj ET EMC /P <>BDC BT 8 0 0 8 77.3366 493.7048 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 79.5594 493.7048 Tm [(If a patient still becomes dehydrated on maximal therapy)74.2(, )]TJ ET EMC /P <>BDC BT 8 0 0 8 77.3366 482.6048 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 79.5594 482.6048 Tm [(subcutaneous saline 0.9% NaCl with up to 8 mmol/L)37.1( magnesium, )]TJ ET EMC /P <>BDC BT 8 0 0 8 77.3366 471.5048 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 79.5594 471.5048 Tm (usually 1-4 times a week may be considered before intravenous )Tj ET EMC /P <>BDC BT 8 0 0 8 77.3366 460.4047 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 79.5594 460.4047 Tm (saline \(0.9% NaCl\) supplementation.)Tj ET EMC /P <>BDC BT 8 0 0 8 209.403 460.4047 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 333.4001 810.4128 Tm -.09 Tc (10.)Tj ET EMC /P <>BDC BT 8 0 0 8 343.2361 810.4128 Tm 0 Tc ( )Tj ET EMC /P <>BDC BT 8 0 0 8 344.7387 810.4128 Tm [(A)55.2( patient who is sodium depleted will have high aldosterone )]TJ ET EMC /P <>BDC BT 8 0 0 8 342.516 798.9128 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 344.7387 798.9128 Tm (concentrations which causes sodium reabsorption in the kidney )Tj ET EMC /P <>BDC BT 8 0 0 8 342.516 787.4128 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 344.7387 787.4128 Tm (at the expense of magnesium and potassium which are excreted. )Tj ET EMC /P <>BDC BT 8 0 0 8 342.516 775.9128 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 344.7387 775.9128 Tm -.015 Tc (Thus, a random urine sodium concentration \(of less than 20 mmol/L\))Tj ET EMC /P <>BDC BT 8 0 0 8 579.1589 775.9128 Tm 0 Tc ( )Tj ET EMC /P <>BDC BT 8 0 0 8 342.516 764.4128 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 344.7387 764.4128 Tm (indicates sodium depletion due to secondary hyperaldosteronism; )Tj ET EMC /P <>BDC BT 8 0 0 8 342.516 752.9128 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 344.7387 752.9128 Tm (treatment aims for a urine sodium concentration of greater than )Tj ET EMC /P <>BDC BT 8 0 0 8 342.516 741.4128 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 344.7387 741.4128 Tm (20 mmol/L. If the kidney has been damaged or the patient takes )Tj ET EMC /P <>BDC BT 8 0 0 8 342.516 729.9128 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 344.7387 729.9128 Tm (a diuretic then the urine sodium concentration may not be )Tj ET EMC /P <>BDC BT 8 0 0 8 342.516 718.4128 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 344.7387 718.4128 Tm (helpful. Magnesium depletion, although often asymptomatic, )Tj ET EMC /P <>BDC BT 8 0 0 8 342.516 706.9128 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 344.7387 706.9128 Tm (is common and treated with correcting hyperaldosteronism, )Tj ET EMC /P <>BDC BT 8 0 0 8 342.516 695.4128 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 344.7387 695.4128 Tm (oral magnesium supplements, reducing fat in the diet \(unless )Tj ET EMC /P <>BDC BT 8 0 0 8 342.516 683.9128 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 344.7387 683.9128 Tm (the patient is malnourished\) and 1-alpha-hydroxy-cholecalciferol )Tj ET EMC /P <>BDC BT 8 0 0 8 342.516 672.4128 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 344.7387 672.4128 Tm [(\(Alfacalcidol\). )55.2(A)55.2( third of serum magnesium is bound to albumin )]TJ ET EMC /P <>BDC BT 8 0 0 8 342.516 660.9128 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 344.7387 660.9128 Tm (so concentrations will appear low in the presence of )Tj ET EMC /P <>BDC BT 8 0 0 8 342.516 649.4128 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 344.7387 649.4128 Tm (hypoalbuminaemia.)Tj ET EMC /P <>BDC BT 8 0 0 8 414.1137 649.4128 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 333.4001 632.2436 Tm -.1042 Tc [(11)-74.2(.)]TJ ET EMC /P <>BDC BT 8 0 0 8 344.7387 632.2436 Tm 0 Tc (Unless the bowel is very short or there is concurrent disease, )Tj ET EMC /P <>BDC BT 8 0 0 8 342.516 620.7436 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 344.7387 620.7436 Tm [(malnutrition is not usually a major problem. However)55.2(, if an oral )]TJ ET EMC /P <>BDC BT 8 0 0 8 342.516 609.2436 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 344.7387 609.2436 Tm (nutritional supplement is needed then a polymeric one is preferred )Tj ET EMC /P <>BDC BT 8 0 0 8 342.516 597.7436 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 344.7387 597.7436 Tm [(ideally with added salt. )55.2(An elemental diet is hyperosmolar so can )]TJ ET EMC /P <>BDC BT 8 0 0 8 342.516 586.2436 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 344.7387 586.2436 Tm (so can exacerbate salt and water losses so should be avoided.)Tj ET EMC /P <>BDC BT 8 0 0 8 567.098 586.2436 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 333.4001 569.0742 Tm -.065 Tc (12.)Tj ET EMC /P <>BDC BT 8 0 0 8 344.7387 569.0742 Tm 0 Tc (Patients admitted with a HOS should not only be rehydrated but )Tj ET EMC /P <>BDC BT 8 0 0 8 342.516 557.5742 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 344.7387 557.5742 Tm (also fully assessed for the aetiology of the HOS and preventative )Tj ET EMC /P <>BDC BT 8 0 0 8 342.516 546.0742 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 344.7387 546.0742 Tm [(measures/treatments given. Generally)74.2(, a patient admitted with a )]TJ ET EMC /P <>BDC BT 8 0 0 8 342.516 534.5742 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 344.7387 534.5742 Tm (HOS will need follow up appointments.)Tj ET EMC /P <>BDC BT 8 0 0 8 481.6996 534.5742 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 333.4001 517.4049 Tm -.08 Tc (13.)Tj ET EMC /P <>BDC BT 8 0 0 8 344.7387 517.4049 Tm 0 Tc [(A)55.2( glucagon-like peptide-2 analogue \(e.g. )18.1(T)110.8(eduglutide\) to mainly )]TJ ET EMC /P <>BDC BT 8 0 0 8 342.516 505.9049 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 344.7387 505.9049 Tm (stimulate upper gut mucosal growth may be considered in those )Tj ET EMC /P <>BDC BT 8 0 0 8 342.516 494.4049 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 344.7387 494.4049 Tm (dependent upon parenteral support, but needs to be given by a )Tj ET EMC /P <>BDC BT 8 0 0 8 342.516 482.9049 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 344.7387 482.9049 Tm (recognised home parenteral nutrition unit or integrated intestinal )Tj ET EMC /P <>BDC BT 8 0 0 8 342.516 471.4049 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 344.7387 471.4049 Tm (failure centre, in accordance with UK NICE guidance.)Tj ET EMC Q /Cs8 cs 0 scn /GS1 gs 27.346 885.582 270.824 13.008 re f BT /TT2 1 Tf 8 0 0 8 31.346 889.5818 Tm 1 scn 0 Tc 0 Tw (BIFA Top Tips - High OP Stoma.qxp_Layout 1 03/05/2023 09:37 Page 2)Tj ET /Cs8 CS 0 SCN 0 J 0 j .65 w 10 M [] 0 d 1 i q 1 0 0 1 28.346 884.409 cm 0 0 m 0 14.173 l S 1 0 0 1 -14.173 -14.173 cm 0 0 m -14.173 0 l S 1 0 0 1 609.449 14.173 cm 0 0 m 0 14.173 l S 1 0 0 1 14.173 -14.173 cm 0 0 m 14.173 0 l S 1 0 0 1 -609.449 -856.063 cm 0 0 m 0 -14.173 l S 1 0 0 1 -14.173 14.173 cm 0 0 m -14.173 0 l S 1 0 0 1 609.449 -14.173 cm 0 0 m 0 -14.173 l S 1 0 0 1 14.173 14.173 cm 0 0 m 14.173 0 l S Q 1 SCN .25 w q 1 0 0 1 28.346 884.409 cm 0 0 m 0 14.173 l S 1 0 0 1 -14.173 -14.173 cm 0 0 m -14.173 0 l S 1 0 0 1 609.449 14.173 cm 0 0 m 0 14.173 l S 1 0 0 1 14.173 -14.173 cm 0 0 m 14.173 0 l S 1 0 0 1 -609.449 -856.063 cm 0 0 m 0 -14.173 l S 1 0 0 1 -14.173 14.173 cm 0 0 m -14.173 0 l S 1 0 0 1 609.449 -14.173 cm 0 0 m 0 -14.173 l S 1 0 0 1 14.173 14.173 cm 0 0 m 14.173 0 l S Q 0 SCN .65 w q 1 0 0 1 311.984 891.409 cm 0 0 m 28 0 l S 1 0 0 1 14 7 cm 0 0 m 0 -14 l S Q q 1 0 0 1 330.984 891.409 cm 0 0 m 0 -2.7615 -2.2386 -5 -5 -5 c -7.7614 -5 -10 -2.7615 -10 0 c -10 2.7614 -7.7614 5 -5 5 c -2.2386 5 0 2.7614 0 0 c s Q 0 scn q 1 0 0 1 329.184 891.409 cm 0 0 m 0 -1.7673 -1.4327 -3.2001 -3.2 -3.2001 c -4.9673 -3.2001 -6.4 -1.7673 -6.4 0 c -6.4 1.7673 -4.9673 3.2 -3.2 3.2 c -1.4327 3.2 0 1.7673 0 0 c f Q 1 SCN .25 w q 1 0 0 1 311.984 891.409 cm 0 0 m 28 0 l S 1 0 0 1 14 7 cm 0 0 m 0 -14 l S 1 0 0 1 5 -7 cm 0 0 m 0 -2.7615 -2.2386 -5 -5 -5 c -7.7614 -5 -10 -2.7615 -10 0 c -10 2.7614 -7.7614 5 -5 5 c -2.2386 5 0 2.7614 0 0 c s Q 1 scn q 1 0 0 1 328.984 891.409 cm 0 0 m 0 -1.6569 -1.3432 -3 -3 -3 c -4.6569 -3 -6 -1.6569 -6 0 c -6 1.6569 -4.6569 3 -3 3 c -1.3432 3 0 1.6569 0 0 c f Q 0 SCN .25 w q 1 0 0 1 328.176 893.601 cm 0 0 m -4.3841 -4.384 l S 1 0 0 1 -4.3841 0 cm 0 0 m 4.3841 -4.384 l S Q .65 w q 1 0 0 1 311.984 7.1728 cm 0 0 m 28 0 l S 1 0 0 1 14 7 cm 0 0 m 0 -14 l S 1 0 0 1 5 -7 cm 0 0 m 0 -2.7614 -2.2386 -5 -5 -5 c -7.7614 -5 -10 -2.7614 -10 0 c -10 2.7614 -7.7614 5 -5 5 c -2.2386 5 0 2.7614 0 0 c s Q 0 scn q 1 0 0 1 329.184 7.1728 cm 0 0 m 0 -1.7673 -1.4327 -3.2 -3.2 -3.2 c -4.9673 -3.2 -6.4 -1.7673 -6.4 0 c -6.4 1.7673 -4.9673 3.2 -3.2 3.2 c -1.4327 3.2 0 1.7673 0 0 c f Q 1 SCN .25 w q 1 0 0 1 311.984 7.1728 cm 0 0 m 28 0 l S 1 0 0 1 14 7 cm 0 0 m 0 -14 l S 1 0 0 1 5 -7 cm 0 0 m 0 -2.7614 -2.2386 -5 -5 -5 c -7.7614 -5 -10 -2.7614 -10 0 c -10 2.7614 -7.7614 5 -5 5 c -2.2386 5 0 2.7614 0 0 c s Q 1 scn q 1 0 0 1 328.984 7.1728 cm 0 0 m 0 -1.6569 -1.3432 -3 -3 -3 c -4.6569 -3 -6 -1.6569 -6 0 c -6 1.6569 -4.6569 3 -3 3 c -1.3432 3 0 1.6569 0 0 c f Q 0 SCN .25 w q 1 0 0 1 328.176 9.3648 cm 0 0 m -4.3841 -4.384 l S 1 0 0 1 -4.3841 0 cm 0 0 m 4.3841 -4.384 l S Q .65 w q 1 0 0 1 7.173 463.291 cm 0 0 m 0 -28 l S 1 0 0 1 7 -14 cm 0 0 m -14 0 l S 1 0 0 1 -7 -5 cm 0 0 m -2.7614 0 -5 2.2386 -5 5 c -5 7.7614 -2.7614 10 0 10 c 2.7614 10 5 7.7614 5 5 c 5 2.2386 2.7614 0 0 0 c s Q 0 scn q 1 0 0 1 7.173 446.091 cm 0 0 m -1.7673 0 -3.2 1.4327 -3.2 3.2 c -3.2 4.9673 -1.7673 6.4 0 6.4 c 1.7673 6.4 3.2 4.9673 3.2 3.2 c 3.2 1.4327 1.7673 0 0 0 c f Q 1 SCN .25 w q 1 0 0 1 7.173 463.291 cm 0 0 m 0 -28 l S 1 0 0 1 7 -14 cm 0 0 m -14 0 l S 1 0 0 1 -7 -5 cm 0 0 m -2.7614 0 -5 2.2386 -5 5 c -5 7.7614 -2.7614 10 0 10 c 2.7614 10 5 7.7614 5 5 c 5 2.2386 2.7614 0 0 0 c s Q 1 scn q 1 0 0 1 7.173 446.291 cm 0 0 m -1.6568 0 -3 1.3431 -3 3 c -3 4.6569 -1.6568 6 0 6 c 1.6569 6 3 4.6569 3 3 c 3 1.3431 1.6569 0 0 0 c f Q 0 SCN .25 w q 1 0 0 1 9.365 447.099 cm 0 0 m -4.3841 4.3841 l S 1 0 0 1 0 4.3841 cm 0 0 m -4.3841 -4.3841 l S Q .65 w q 1 0 0 1 644.795 463.291 cm 0 0 m 0 -28 l S 1 0 0 1 6.9999 -14 cm 0 0 m -14 0 l S 1 0 0 1 -6.9999 -5 cm 0 0 m -2.7615 0 -5.0001 2.2386 -5.0001 5 c -5.0001 7.7614 -2.7615 10 0 10 c 2.7614 10 5 7.7614 5 5 c 5 2.2386 2.7614 0 0 0 c s Q 0 scn q 1 0 0 1 644.795 446.091 cm 0 0 m -1.7673 0 -3.2001 1.4327 -3.2001 3.2 c -3.2001 4.9673 -1.7673 6.4 0 6.4 c 1.7673 6.4 3.2 4.9673 3.2 3.2 c 3.2 1.4327 1.7673 0 0 0 c f Q 1 SCN .25 w q 1 0 0 1 644.795 463.291 cm 0 0 m 0 -28 l S 1 0 0 1 6.9999 -14 cm 0 0 m -14 0 l S 1 0 0 1 -6.9999 -5 cm 0 0 m -2.7615 0 -5.0001 2.2386 -5.0001 5 c -5.0001 7.7614 -2.7615 10 0 10 c 2.7614 10 5 7.7614 5 5 c 5 2.2386 2.7614 0 0 0 c s Q 1 scn q 1 0 0 1 644.795 446.291 cm 0 0 m -1.6569 0 -3 1.3431 -3 3 c -3 4.6569 -1.6569 6 0 6 c 1.6569 6 3 4.6569 3 3 c 3 1.3431 1.6569 0 0 0 c f Q 0 SCN .25 w q 1 0 0 1 646.987 447.099 cm 0 0 m -4.384 4.3841 l S 1 0 0 1 0 4.3841 cm 0 0 m -4.384 -4.3841 l S Q endstream endobj 141 0 obj <>/XObject<>/ExtGState<>/ColorSpace<>>> endobj 145 0 obj <>stream H6THHP(.M0f endstream endobj 6 0 obj <> endobj 5 0 obj <> endobj 143 0 obj <>stream Adobed   l7    o!1AQ"aq2 #BR3$bC4% rS&cD5Ts6'E7F򃓣dU()8GHVe*9:IJWXYZftugvwhijxyzi!1AQa"q2#BR 3br$’Csc%4S5&DTdEU' 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