The loss of fluid and electrolytes from a high output ileostomy (>1200ml/day) can quickly result in dehydration and if not properly managed may cause acute renal failure. The management of a high output ileostomy is based upon 3 principles; correction of electrolyte disturbance and fluid balance; pharmacological reduction of ileostomy output and treatment of any underlying identifiable cause. There is an increasing body of evidence to suggest that C. difficile may behave pathologically in the small intestine and producing a spectrum of enteritis that mirrors the well recognised colonic disease manifestation. Clinically this can range from high output ileostomy to fulminant enteritis. We report two cases of a high output ileostomy associated with enteric C. difficile infection and propose that the management algorithm of a high output ileostomy should include exclusion of small bowel C. difficile.