CPT2: GI 9 (Ileostomies and colostomies)

Question 1

What percentage of patients with Crohn’s and Ulcerative colitis require surgery at some point?

Answer 1

• 80% Crohns
• 20% Ulcerartive colitis

Question 2

Why might surgery be required?

Answer 2

• Strictures
  
  • Scarring/ narrowing - lead to blockage needs removed
• Fistulae (Crohn’s only)
  
  • Tunnel into adjacent organ
• Medical failure
  
  • Other treament options failed
• Perforation
  
  • Tunnel into abdominal cavity (infection)
• Colonic cancer
  
  • Remove tumour
• Patient preference (Ulcerative colitis)
  
  • Removal of colon means no UC

Question 3

What surgeires is there?

Answer 3

Part of intestine brought through skin and stiched there by surgen to allow contents to leave body

colostomy - part of colon removed

Ileostomy - colon removed. part of small intestine might be too. Terminal ileum gone.

Question 4

Why is terminal ileum important?

Answer 4

Enterohepatic recyling

vit b12 absorb

Question 5

What are conderations with patients with ileostomy?

Answer 5

Ileostomy:

• Avoid modified release and enteric coated preparations in ileostomies
  
  • Release contents over length of intestines. As intestine shortened less time to absorb.
• Iron preparations can irritate stoma site
• B12 deficiency (removal of terminal ileum)
  
  • Terminal ileum removed
• Be aware of nephrotoxics and renally excreted medicines
  
  • Shortened intestine means less water abosrbed so dehydration, therefore kideny damage. So these medications can damage further
• Be aware of sorbitol (high osmolarity) content in liquid medications – promotes fluid loss
• Medicines may be less effective due to fast transit time – contraceptives, antiepileptics, thyroxine
• High output >2 litres/day which can lead to dehydration and electrolyte imbalance

Question 6

High output >2 litres/day which can lead to dehydration and electrolyte imbalance in people with ileostomies.

What can be given to help this and advice?

Answer 6

• Loperamide orodispersible 4mg QDS up to 96mg/day! QT risk
  
  • Slows intesinal motility allowing more time for medication, fluids and electrolytes to be absorbed.
  • Higher dose than normal as loperamide normally goes through enterohepatic recycling therefore a lot of this medication is lost to stoma bag.
• Codeine
  
  • 2nd line add in therapy
  • Slows gastric motility again allowing for more absorption time but
  • Active in brain so can cause confusion, dizziness etc
• PPI/H2RA – antisecretory (orodispersible)
  
  • Reduces gastric sectrion and therefore help decrease fluid loss
• DS Dioralyte/St Mark’s solution
  
  • isotonic solutions containing the correct amount of Na+/ electrolytes
  • Used to rehydrate
• Isotonic fluids – avoid electrolyte poor fluids (tea, water) which encourage Na loss
• Avoid dehydrating/prokinetic medicines – diuretics, metoclopramide, metformin
• Artificial saliva

Multi Disaplinary Team working – dietician, stoma nurse, doctor, pharmacist

Question 7

What are considerations of patients with colostomies?

Answer 7

Colostomy

• Iron preparations can irritate stoma site
• ?Nicorandil and stoma ulceration
• Antacids may cause constipation or diarrhoea
• ?MR preparations – less suitable
• Antibiotics may promote diarrhoea
• MDT working – dietician, stoma nurse, doctor, pharmacist

Question 8

Why should hyper/hypotonic solutions be avoided?

Answer 8