Lessons 12-15: Ileostomy In Adults Flashcards
Surgical Indications
- 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
Familial Adenomatous Polyposis (FAP)
- 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
Gardner’s Syndrome
- 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
Peutz-Jegher Syndrome
- 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
Ulcerative Colitis
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
Crohns Colitis
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
IBD Management - Medical
Goals: induce remission and prevent relapse
- Approach is dictated by location and severity
- Pharmacological > surgical
IBD Management - Nutritional
- Weight loss and nutritional deficits common
- Hypermetabolic state d/t inflammation
Reduced oral intake - Compromised nutrients absorption
IBD Management - Patient Education
No clear causative factors
Importance of medical follow up + adherence to management plan
IBD Management - Support + Counselling
- Impact of chronic disease with variable trajectory
- Impact on usual activities, occupation, and relationships
- Male: oligospermia
- Female: medical management for normal pregnancy and delivery
Aminosalicylates
- 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)
Corticosteroids
- 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
Immunomodulators
- helps control immune function
- for both induction and maintenance
T-Cell Inhibitors
- for induction therapy
Ie. Cyclosporine + tacrolimus
Biologic Agents
- Block specific inflammatory agents
- For induction and maintenance
- Anti-tumor necrosis factor antibodies
- Anti-integrin/anti-adhesion molecules
Rx Management of Ulcerative Colitis (mild to moderate)
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
Rx Management of Ulcerative Colitis (severe)
Systemic therapy for induction and maintenance
- Steroids - induction only
- T-cell inhibitors
- Biologics
- Immunomodulators (sometimes added for maintenance)
Rx Management of Crohns
Comparable to UC management
- Biologics
- Methotrexate
- 5-ASA
T-cell inhibitors not as effective
Ulcerative Colitis - Surgical Intervention
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
Crohns Colitis - Surgical Intervention
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
Ileostomy - Normal Function
- 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
Ileostomy - Pouch Selection
Drainable pouch is default
- Closed-ended ONLY if unable to empty
High output pouch essential for first little bit
Ileostomy - Pouch Emptying
- 3-4 times/day
- When ⅓-½ full
- Encourage use of pouch and room deoderants
Ileostomy - Pouch Change
- Standard procedure
- Drainage is enzymatic
— MUST protect periwound skin well
— Paste or barrier ring essential
Ileostomy - Odor Control
- 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
Ileostomy - Gas Control
- 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
Ileostomy - Dietary Guidelines
- 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
Foods High in Insoluble Fiber
Raw + crisp veggies
Nut + seeds
Dried fruits, trail mix, granola
Peels
Membranes
Mushrooms
Olives
Coconut
Corn
Ileostomy - Dehydration
- 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
Ileostomy - High Volume Output
> 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
Food Blockage - Partial Obstruction
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
Food Blockage - Complete Obstruction
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
Ileostomy - Medications
- No laxatives
- Avoid time-release/enteric coated
- Split or crush large tabs
- Liquid + chewable forms are preferable
B12 Deficiency
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
Renal Calculi
Ileostomy patient at increased risk
- Chronic dehydration
- Concentrated urine
- Loss of bicarbonate cases urine to be acidic
- High calcium and oxalate levels in urine
