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Ostomy 2.2 > Lessons 12-15: Ileostomy In Adults > Flashcards

Lessons 12-15: Ileostomy In Adults Flashcards

1
Q

Surgical Indications

A
  • usually temp diversion/protection of distal anastomosis dt delayed healing
    — DM, ESRD, ESLD
  • Steroid use
  • Tension on anastomosis
  • Intra-abdominal infection

Construction = diverting loop ileostomy
Takedown = 3-6 months

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2
Q

Familial Adenomatous Polyposis (FAP)

A
  • Genetic disorder causing mutation of tumor suppression
  • Results in thousands of polyps in colon and rectum +/- extra intestinal malignancies
  • 100% risk of colorectal cancer

Management
- Medical
— Sigmoidoscopy/colonoscopy Q1-2 years
— Upper GI + thyroid screening
— Genetic counseling
- Surgical
— Proctocolectomy with continent fecal diversion
— ileal pouch with anastomosis +/- permanent ileostomy

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3
Q

Gardner’s Syndrome

A
  • Variation of FAP
  • Development of adenomatous polyps in colon + rectum
    — Osteomas, epidermoid cysts, and soft tissue tumors

Management
- Medical
— NSAIDS
— GI protection
— Routine endoscopy
- Surgical
— Only if polyps causing obstruction
— Colectomy not recommended

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4
Q

Peutz-Jegher Syndrome

A
  • Large pedunculated polyps with central core of smooth muscle
  • Commonly in jejunum, not exclusive
  • Mucocutaneous pigmentation on buccal mucosa, lips, eyes, and perianal area

Management
- Medical
— Upper/lower GI endoscopy
— Screening for malignancies
- Surgical
— Resection only for colorectal cancer or obstructing lesion

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5
Q

Ulcerative Colitis

A

Anatomical
- Rectum always involved
- variable length of colon

Pattern
- Continuous and circumferential
- Progresses from distal to proximal

Bowel layers
- Mucosa
- Deep layers only with fulminant disease

Clinical presentation
- Frequent bloody stools
- Fecal urgency
- Crampy pain, weight loss, fatigue, fever, night sweats
- No perinatal disease, no fistulas

Endoscopy
- Mucosal ulcerations
- No strictures

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6
Q

Crohns Colitis

A

Anatomical
- Can occur anywhere in GI tract
- Distal bowel most common

Pattern
- Skip areas common
- Normal bowel varies with areas of inflammation

Bowel layers
- Transverse/full thickness

Clinical presentation
- Abdo pain
- Frequent loose stools
- Weight loss
- Nausea/vomiting
- Frequent bloody stools

Endoscopy
- Cobble-stone appearance
- Strictures with longstanding disease

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7
Q

IBD Management - Medical

A

Goals: induce remission and prevent relapse

  • Approach is dictated by location and severity
  • Pharmacological > surgical
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8
Q

IBD Management - Nutritional

A
  • Weight loss and nutritional deficits common
  • Hypermetabolic state d/t inflammation
    Reduced oral intake
  • Compromised nutrients absorption
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9
Q

IBD Management - Patient Education

A

No clear causative factors

Importance of medical follow up + adherence to management plan

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10
Q

IBD Management - Support + Counselling

A
  • Impact of chronic disease with variable trajectory
  • Impact on usual activities, occupation, and relationships
  • Male: oligospermia
  • Female: medical management for normal pregnancy and delivery
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11
Q

Aminosalicylates

A
  • For mild-moderate disease
  • Systemic and topical format
  • Need to protect active agent from proximal bowel breakdown

Topical
- Mesalamine - enema or suppository

Systemic
- Sulfasalazine (5-ASA to Sulla and azo bond)
— Breakdown in colon to release 5-ASA
- Balsalazide (5-ASA to non-Sulla carrier)
- Mesalamine (5-ASA with coating that dissolves in colon)

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12
Q

Corticosteroids

A
  • Extremely effective but ++ side effects
  • Can induce remission
  • Multiple forms available

Budesonide
- Rapid uptake by mucosal tissue
- Minimal systemic effects d/t hepatic inactivation
- Can get benefits of steroids w/o side effects

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13
Q

Immunomodulators

A
  • helps control immune function
  • for both induction and maintenance
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14
Q

T-Cell Inhibitors

A
  • for induction therapy

Ie. Cyclosporine + tacrolimus

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15
Q

Biologic Agents

A
  • Block specific inflammatory agents
  • For induction and maintenance
  • Anti-tumor necrosis factor antibodies
  • Anti-integrin/anti-adhesion molecules
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16
Q

Rx Management of Ulcerative Colitis (mild to moderate)

A

Determined by location of inflammation

Limited to rectum/distal sigmoid = topical therapy
- Topical 5-ASA
- Topical steroids

Extends beyond distal sigmoid
- Topical 5-ASA
- Topical steroids
- Systemic 5-ASA with budesonide

17
Q

Rx Management of Ulcerative Colitis (severe)

A

Systemic therapy for induction and maintenance
- Steroids - induction only
- T-cell inhibitors
- Biologics
- Immunomodulators (sometimes added for maintenance)

18
Q

Rx Management of Crohns

A

Comparable to UC management
- Biologics
- Methotrexate
- 5-ASA

T-cell inhibitors not as effective

19
Q

Ulcerative Colitis - Surgical Intervention

A

Proctocolectomy is curative
- Proctocolectomy with ileal pouch anal anastomosis
- Proctocolectomy with continent ileostomy (koch pouch)
- Proctocolectomy with end ileostomy

Indications
- Persistent disease with refractory bleeding
- Fulminant disease resulting in toxic megacolon
- Inability to wean patients off steroids
- Failure to thrive in children
- Development of colonic dysplasia or adenocarcinoma

20
Q

Crohns Colitis - Surgical Intervention

A

Surgery isn’t curative - disease can return elsewhere in GI tract

Options
- If Crohn’s colitis - Proctocolectomy with end ileostomy
- Segmental disease - bowel resection with anastomosis
- Fistula/abscess requiring bowel rest - diverting ostomy

21
Q

Ileostomy - Normal Function

A
  • Ileus resolves in 24 - 48 hours
  • Can stimulate peristalsis with gum chewing and mobility
  • Initial ileostomy output is low output, viscous, and dark green

High output phase
- Can take several weeks for small bowel to adapt
- Output averages 1-2L/day
- Ileostomy replacements essential
— 1:1 or ½:1
- Long term output = 500 - 1L/day

22
Q

Ileostomy - Pouch Selection

A

Drainable pouch is default
- Closed-ended ONLY if unable to empty

High output pouch essential for first little bit

23
Q

Ileostomy - Pouch Emptying

A
  • 3-4 times/day
  • When ⅓-½ full
  • Encourage use of pouch and room deoderants
24
Q

Ileostomy - Pouch Change

A
  • Standard procedure
  • Drainage is enzymatic
    — MUST protect periwound skin well
    — Paste or barrier ring essential
25
Q

Ileostomy - Odor Control

A
  • Clean bottom of pouch thoroughly
  • Pouches are odor-proof

Rx
- Chlorophyllin 100 mg PO OD - BID
- Bismuth Subgallate 1-2 tabs PO TID - QID
— Thickens and deodorizes stool
— Constipation risk!
— Color becomes dark green/black

26
Q

Ileostomy - Gas Control

A
  • High volumes of gas common post-op d/t bowel prep + OR

Management
- Identify gas forming foods
- Education on “lag-time”
- Benefit of timing between food intake and gas output
- Can muffle stoma to decrease sound

Rx
- Beano - decreased gas formation
- Simethicone - reduces size of gas bubbles

27
Q

Ileostomy - Dietary Guidelines

A
  • Minimal intake restrictions

1st 6 - 8 weeks postop
- Restriction of insoluble fiber until stomal edema resolves
- Os is quite narrow initially
- Fiber bolus could create food blockage

8 weeks onwards
- Add fiber foods back gradually
- If no issues with cramping, gradually increase volume
- Chew well
- Maintain fluid intake

28
Q

Foods High in Insoluble Fiber

A

Raw + crisp veggies
Nut + seeds
Dried fruits, trail mix, granola
Peels
Membranes
Mushrooms
Olives
Coconut
Corn

29
Q

Ileostomy - Dehydration

A
  • Most common reason for readmission
  • Patient needs 2.5 - 3L/ day
  • Drink extra glass of fluid when pouch emptied
  • Needs electrolytes
  • Increase intake during periods of increased loss
30
Q

Ileostomy - High Volume Output

A

> 1.2 L/Day = high dehydration risk

Options
- Low residue diet
- BRAT diet
- Soluble fiber to thicken stool +/- slows transit time
- Rx
— Diphenoxylate: max 5 mg PO TID - QID
— Loperamide: max 16 mg PO OD
- IV fluids
- High output pouch

31
Q

Food Blockage - Partial Obstruction

A

Causes fecal stasis above blockage

S/S
- Watery + foul smelling output
- Cramps pain
- Abdo distension
- Stomal edema
- N/V

Management
- Avoid solid + increases PO fluids
- If stomal edema, cut new pouch to accommodate
- Warm bath and relax muscles
- Peristomal massage to promote bonus passage
- Knee-chest position

32
Q

Food Blockage - Complete Obstruction

A

S/S
- Minimal to no output
- Intense cramping
- Abdo distention
- Stomal edema
- N/V

Management
- Try options for partial obstruction
- NPO
- Go to ED
— X-ray or CT for confirm obstruction
— Analgesics +/- antiemetics
— IV fluids
— ileal lavage

33
Q

Ileostomy - Medications

A
  • No laxatives
  • Avoid time-release/enteric coated
  • Split or crush large tabs
  • Liquid + chewable forms are preferable
34
Q

B12 Deficiency

A

B12 only absorbed in terminal ileum
- If large portion removed = B12 deficiency

If at risk
- Check levels 3-4 times/year
- Start replacements

Symptoms
- Anemia
— Fatigue
— Activity intolerance
- Deficiency
— Neuropathy
— Cognitive impairment
— Depression

35
Q

Renal Calculi

A

Ileostomy patient at increased risk
- Chronic dehydration
- Concentrated urine
- Loss of bicarbonate cases urine to be acidic
- High calcium and oxalate levels in urine

Ostomy 2.2 (15 decks)

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