Lessons 8-11: Colostomy In Adults Flashcards
Colostomy Options
- end stoma
- end stoma with distal bowel and sphincter intact (Hartmann’s Pouch)
- end stoma with mucous fistula
- loop colostomy
Indications for temporary colostomy - colonic perfusion
- trauma, ischemic damage, or severe damage
- sudden spillage of stool and bacteria into abdo
- diverticulitis
Indications for temporary colostomy - colonic obstruction
- tumour, structures, volvulus
- goal is to restore fecal elimination and prevent perforation
Indications for temporary colostomy - protection of distal anastomosis
- Anastomosis under tension
- Anticipated delays in healing d/t comorbidities
- Overwhelming infection/sepsis/inflammation
Indications for temporary colostomy - bowel rest for refractory inflammation
- crohns colitis
- crohns proctitis
- anorectal disease
Indications for temporary colostomy - healing
- rectovaginal fistula
- complex pressure injuries
- extensive perineal wounds
Indications for permanent colostomy
- intractable crohns with rectum and anal canal
- cancer involving distal rectum
- intractable fecal incontinence
- colorectal cancer
Colorectal cancer - Etiology
- Adenocarcinoma most common
- Starts as single cell that transforms and begins abnormal growth
Colorectal cancer - Risk Factors
Non-modifiable
- Age >50
- Family history of polyps or colorectal cancer
- Genetic predisposition
- IBS
Modifiable
- High fat, low fiber diet
- Sedentary lifestyle
- Obesity
Colorectal cancer - clinical presentation
- Blood in stool
- Ribbon-like stools
- Generalized abdo pain
- Weight loss
- Fatigue and anemia (d/t chronic bleeding)
Colorectal cancer - diagnostics
Colonoscopy and biopsy
- Metastatic workout
- MRI or endoscopic ultrasound
- CT chest/abdo/pelvis
- Carcinoembyronic antigen (CEA)
Colorectal cancer - staging
Stage 0: tumor limited to mucosal layer of bowel
Stage 1: tumor confined to bowel wall with negative nodes
Stage 2: tumor extended to through outer layers of bowel with negative nodes
Stage 3: tumor extends to/through outer layers of bowel with positive nodes
Stage 4: any degree of tumor invasion with positive nodes and distant metastasis
Colorectal cancer - treatment
Stages 1-3
- Surgical resection with end-to-end anastomosis
- All colon between main vessels proximal and distal to tumor
- Wide margins
- If large obstructing tumor, possible temp diversion
Stage 4
- If resectable = surgical resection with chemo
- If unresectable and obstructing = fecal diversion with chemo
- If unresectable and nonobstructing = chemo only
Colorectal cancer - surgical resection
Goal: remove segment of rectum, tumor, adjacent tissues, and regional lymph nodes
Stage 1 = Transanal resection
- Mid to upper rectum = lower anterior resection
- Distal rectum = abdominal perineal resection
Surgical Construction - End Stoma
- singe opening
- For abdo perineal resection
- Distal bowel, anal canal, and sphincters removed
- Colostomy is permanent
- Proctectomy - perineal wound d/t rectal resection
— Anal opening closed with sutures +/- drain
Surgical Construction - Loop Stoma
- 2 openings
- Proximal - mouth to stoma
- Distal - stoma to anus
- Disease/damaged section of bowel is removed
- Usually temporary
- As risk for diversion colitis if reversal is delayed
— Gut flora becomes imbalanced from isolation from functional colon
Surgical Construction - End Stoma with Mucus Fistula
- 2 openings
- Diseased/damaged section of bowel removed
- Both ends of bowl on surface as stomas
- Proximal = stool (needs pouch)
- Distal = mucous
- If close together, can pouch as one
Surgical Construction - Loop Colostomy
- Bowel is not divided
- Entire loop of bowel brought to surface and stabilized
- Proximal = stool
- Distal = mucous
- Loop support in place for 5-14 days
- Pouch over or around
Implications for Anatomical Location - Cecostomy
- For obstructing mass in colon
- Not a true stoma - a tube diversion
- Output is semi-liquid and malodorous
- Begins functioning at 2-3 days postop
Implications of Anatomical Location - Ascending Colostomy
- Output like cecostomy
- Output is semi-liquid and malodorous
- Requires drainage pouch
- Begins functioning at 2-3 days postop
Implications of Anatomical Location - Transverse Colostomy
- Output is mushy and malodorous
- A large stoma - requires pouch
- Begins functioning 3-5 days postop
Implications of Anatomic Location - Descending or Sigmoid Colostomy
- Output is pasty-formed, mild odor
- Can be irrigated
- Requires pouch - drainable or closed-end
Colostomy Self Care - Pouch Selection
- All patients should be taught with drainable pouch
- Can transition to closed end if option
- Usually for descending or sigmoid colostomy
Colostomy Self Care - Pouch Emptying
- When ⅓ - ½ full
- Usually 1-3 times day
- Either open and drain (drainable) or removed and replace (closed-end)
Colostomy Self Care - Pouch Change
- Standard approach
- Remove, skin cleanse, measure, cut, apply
- Can use paste/barrier ring for liquid/mushy stool
Colostomy Self Care - Odor Control
- Clean bottom of pouch thoroughly
- Pouches are usually odor-proof
- Use of pouch and room deodorants
- 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
Colostomy Self Care - Gas Control
- Colostomy > ileostomy
- Identify gas-forming foods
- Lag time from intake to gas (usually 4-8 hours)
- Rx
— Beano (gas-controlling)
— Simethicone (reduces size of gas bubbles)
Colostomy Self Care - Dietary Guidelines
- no absolute
- fiber and fluid intake critical
Constipation
- Descending and sigmoid colostomy at greatest risk
- Fluids + fiber!
- Signs/symptoms
— Hard stools
— Bloating
— Cramping
— No ostomy output >24 hours - Management
— OTC laxatives
— Irrigation PRN
Diarrhea
- Common in ascending or transverse colostomy
- Management
— Fluid + electrolyte intake
— BRAT diet
— Can take liquid antidiarrheal meds
Colostomy Irrigation
- Regulates stool elimination via “training” the bowel on a strict schedule
- Goal is modified continence when the bowel empties on a schedule with minimal leakage between irrigations
- Can be time consuming and required strict schedule
Colostomy Irrigation - Contraindications
- Children
- Poor prognosis
- Active bowel disease
- Hx of frequent diarrhea
- Ongoing chemotherapy
- Stoma complications
Colostomy Irrigation - Procedure
- Fill irrigation bag with 1 L tepid water
- Flush air from tubing
- Attach irrigation sleeve to stoma
- Lubricate cone tip and insert into stoma
- Open clamp and allow water to flow
- Goal = 1 L fill in 5-10 mins
- When patient feels full, clamp and remove
- Close top of irrigation sleeve and wait
- Once returns are complete, remove sleeve and pouch up
Colostomy Irrigation - Complications
- difficult instillations
- failure of returns
- vasovagal response
- rebound constipation
