Stoma care and complications

Question 1

What interventions can help patiets adapt to temporary or permanent ostomies?

Answer 1

• Preoperative stoma site selection by ostomy nurse specialist (enterostomal therapy nurse, wound
  ostomy continence nurse) or experienced surgeon.
  
  • associated with fewer ostomy-related complications e.g. leakage, dermatitis
  • improved patient’s ability to care for ostomy independently
  • reduced health care costs
• A strong focus on individualized patient education, with a preoperative and postoperative component
• Supportive counseling for all patients preoperatively and in-depth counseling for any patient who is
  having trouble adapting.
  
  • ostomy nurse specialist involvement or stoma support groups helps to improve long-term outcomes and reduce complication rates

Question 2

What are the differences between one piece vs two piece stoma bags?

Answer 2

The main functions of ostomy pouches are

• contain ostomy effluent
• contain odor
• protect the peristomal skin.

One-piece systems include a protective skin barrier with a tape border fused to an odor-proof pouch.

• offer simplicity, and many of these systems provide flexibility, which is important for the patient whose stoma is located in a deep crease.

Two-piece systems include a protective skin barrier with a tape border and flange or adhesive landing zone to which the patient attaches a separate odor-proof pouch.

• advantage is it can be replaced without having to remove the protective skin barrier each time.

Question 3

Pouch placement

• what strategies should be done to promote pouch adherence to skin, minimize leakage, and protect peristomal skin?

Answer 3

• Selecting a pouching system that conforms to the abdominal contour at the stoma location. Some examples are
  
  • A flat pouch with a rigid flange requires a relatively flat, at least 4 cm pouching surface that is
    distant from scars, skin creases or folds, and bony prominences
  • A stoma located in a concave abdominal plane may be best managed with a convex pouching
    system, which can increase protrusion of the stoma and improve drainage of effluent into the
    pouch.
  • Transverse loop colostomies are typically large stomas in the upper quadrants that are difficult to
    conceal, and prolapse is more common.
  • Cecostomies, now rarely performed, are typically skin-level stomas located adjacent to the groin
    crease, which compromises pouch adherence.
• Sizing the opening of the protective skin barrier to minimize the amount of exposed skin.
  
  • ​Stomas often change shape and size in the postoperative period. After the stoma has assumed its final appearance (usually several weeks after construction), a precut protective skin barrier may be supplied so the patient or their care givers do not need to cut out the barrier ring each time a new appliance is placed.
• Using adjunctive products to improve the fixation of the pouch (adhesive agents, Skin Prep) and to prevent irritation and injury to the peristomal skin (skin barrier paste, skin barrier powder, skin barrier ring)
• Loop ileostomies are typically more difficult to manage than end ileostomies because the stoma frequently empties close to the skin surface. Because the small bowel effluent is rich in proteolytic enzymes, the patient with an ileostomy must exercise particular caution in managing the peristomal skin.
  
  • These patients should routinely use barrier wafers, rings, and/or paste to assure that their skin is not exposed to the drainage and must treat any minor skin damage aggressively to prevent
    progression.

Question 4

Pouch emptying and care

• How do you reduce odor if the patient is complaining of this?

Answer 4

• Odor and gas are common concerns for any individual with an ostomy. The patient should be assured that ostomy pouches are odor proof, but when the pouch is emptied, odor is normal.
• Simple strategies can help reduce odor:
  
  • Emptying the pouch when it is approximately one third full will prevent disruption of the pouch seal
    from excess weight.
  • Changing the pouch one to two times weekly, and as needed, for any signs of leakage, or for
    itching/burning of the peristomal skin.
  • Keeping the tail of the pouch clean so that it does not become a source of odor. This can be accomplished by everting the tail of a pouch prior to emptying it. For some pouches that have an integrated closure mechanism, tail eversion is not required.
  • Using a room spray or pouch deodorant to minimize odor associated with emptying.
• If oder is still a concern,
  
  • bismuth subgallate or chlorophyllin copper complex effectively reduces stool odor when taken routinely
    
    • Bismuth subgallate tends to thicken the stool, so it may best be used for the patient with an ileostomy or proximal colostomy.
    • Chlorophyllin may have a slight diarrheal effect and is more appropriate for the patient with a
      descending/sigmoid colostomy.

Question 5

Do you need to tell patients to adhere to special diet with GI ostomies?

Answer 5

• No special diet needed
• Warn patients that certain foods can increase flatulence
• The carbohydrate raffinose is poorly digested and leads to gas production by the action of colonic bacteria.
  
  • Common foods containing raffinose include beans, cabbage, cauliflower, brussel sprouts, broccoli, and asparagus.
  • Starch and soluble fiber are other forms of carbohydrates that can contribute to gas formation. Potatoes, corn, noodles, and wheat produce gas while rice does not.
  • Soluble fiber (found in oat bran, peas and other legumes, beans, and most fruit) also causes gas.
• Patients should also be given an explanation that the usual “lag time” between ingestion of a gasproducing
  food and actual flatulence is between two and four hours for ileostomy and six to eight hours for
  distal colostomy.
• In addition to dietary modifications, ileostomy patients should be taught to avoid drinking carbonated drinks, drinking through straws, chewing gum, and smoking, since these measures tend to increase gas ingestion.
• Strategies to control gas include measures to reduce the volume of gas produced or to affect the “timing”
  of flatulence, “muffling” measures, and “venting” strategies. Dietary modifications and over-the-counter
  gas-reducing agents (eg, Beano and Gas-X) help reduce the volume of gas. “Muffling” measures include
  layers of clothing and light pressure exerted against the stoma with the hand or arm when flatulence is
  anticipated. For patients with large volumes of gas, there are pouching systems with filters, which vent and
  deodorize flatus; there are also “add-on” flatus filters that can be used with any pouching system

Question 6

• What influences the type and volume of output (effluent) for stomas?
• How much output do ileostomies put out?
• Why do ileostomy effluent irriate the skin?

Answer 6

• location of the stoma relative to the ileocecal valve
• Ileostomies, cecostomies, and ascending colostomies typically produce output (effluent) >500 mL per day that contains digestive enzymes, which is irritating to the
  mucosa and skin.

Question 7

• What’s the most common cause of hospitalization post-ileostomy surgery?
• What are prevention recommendations?
• Average output for ileostomy patient per day?
• How does output change if loop ileostomy is performed with a pelvic pouch procedure?
• What electrolytes are lost in ileostomy effluent?

Answer 7

• Dehydration, occurs in up to 30% of patients post-loop ileostomy creation
• Hydration recommendations vary
  
  • Regardless, patients with an ileostomy should be instructed to increase their daily fluid intake beyond the recommended adequate intake (3 L for men and 2.2 L for women) for the general population by at least 500 to 750 mL, and to drink even more during periods of high-volume output or heavy sweating.
  • Preferred fluids include water, broth, vegetable juices, and some sports drinks, but patients should be advised that certain sports drinks may not be absorbed and may even exacerbate stoma output and dehydration. The use of pediatric electrolyte solutions (eg, PediaLyte, Emergen-C) is preferable to the use of sports drinks.
  • Ileostomy patients and patients with ascending colostomies should be taught the importance of adequate daily fluid intake.
• Average output for the ileostomy patient ranges from 500 to 1300 mL a day; during the early postoperative period and episodes of gastroenteritis, daily output can be 1800 mL or even higher.
• A loop ileostomy performed in conjunction with a pelvic pouch procedure is located more proximally in the ileum and is associated with even more fluid and enzymatic output. This daily fluid loss places the ileostomy patient at greater risk for dehydration, especially during episodes of increased output or heavy
  perspiration.
• Ileostomy effluent contains significant amounts of sodium and potassium. Patients should also be taught
  the signs and symptoms of fluid-electrolyte imbalance and the importance of prompt treatment should these symptoms occur. These include dry mouth, reduced urine output, dark concentrated urine, feelings of dizziness upon standing, marked fatigue, and abdominal cramping.

Question 8

How can you minimize the risk of dehydration (besides hydration) for ileostomy patients?

Answer 8

• Protocols and pathways have been proposed to minimize dehydration and readmission in patients with new ileostomies.
• Using combinations of
  
  • preoperative teaching
  • in-hospital engagement of the nurses and Wound, Ostomy and Continence care (WOCN) teams
  • in-hospital involvement and encouragement of patients and families in stoma care
  • postdischarge counseling
  • tracking of intake and output has effectively reduced hospital readmission while maintaining an appropriate hospital length of stay

Question 9

High-output ileostomy

• Definition?
• How do you treat high-output ileostomy (first line)?

Answer 9

• High-output ileostomy is defined as > 1.5 L/day
• Treatment should include soluble fiber supplementation, also referred to as bulk-forming laxatives, since they
  are primarily used to treat constipation
  
  • Metamucil, psyllium, Konsyl, FiberCon, Fiber Gummies
  • Patients may slowly increase supplementation up to four times daily and also at double doses.
• Medical management of patients with inappropriately elevated ileostomy outputs is required in patients
  who do not respond to fiber supplementation and includes antimotility agents (eg, loperamide [Imodium],
  diphenoxylate and atropine [Lomotil], octreotide, cholestyramine, and, rarely, tincture of opium).
  
  • We usually start with loperamide because it is over the counter and has fewer side effects. The starting
    dose for loperamide is one tablet two to three times a day based on stoma output.
  • In all cases, adjustments should be made slowly and not in combination, as this could lead to a paralytic ileus or an obstructive pattern.

Question 10

High-output ileostomy

• What happens if first line treatment fails?

Answer 10

• Medical management of patients with inappropriately elevated ileostomy outputs is required in patients who do not respond to fiber supplementation and includes antimotility agents
  
  • loperamide [Imodium]
  • diphenoxylate and atropine [Lomotil]
  • octreotide
  • cholestyramine
  • rarely, tincture of opium
• We usually start with loperamide because it is over the counter and has fewer side effects. The starting dose for loperamide is one tablet two to three times a day based on stoma output.
• In all cases, adjustments should be made slowly and not in combination, as this could lead to a paralytic ileus or an obstructive pattern.
• Rarely, patients with difficult-to-control ileostomy output may need to be maintained on IV hydration via a long-term indwelling venous access cannula. Those with persistent, recurrent, or difficult-to-manage complications from loop ileostomy creation should be considered for early reversal of the stoma and restoration of intestinal continuity, when feasible.
  
  • Ileostomy patients with high output may need to change to a protective skin barrier that is extended wear
    and/or the addition of a skin barrier ring to prevent washout of the skin barrier.
  • Also, changing to a high output pouch would be beneficial for patient management.