Stoma/colostomy Flashcards
TYPES OF STOMA - ILEOSTOMY
i) name three things that should be checked when a patient comes in with a stoma
ii) what is an ileostomy? give three indications? what is produced
iii) what is an end ileostomy? which part of the intestine does it involve
iv) what is a loop ileostomy? what is it often used for
v) what is a double barrelled stoma
vi) what side of abdo is it usually placed on? what does spouted mean?
i) what kind of bag is used, any leaks, is the skin clean
ii) small bowel is used > bag
- used in IBD (UC and crohns)
- used if there is an anastomosis or tumour downstream
- produce liquid stool
iii) permanent ileostomy with one opening from ilium to the skin
iv) temp ileostomy with prox and distal opening of small bowel sharing a posterior wall
- one side is active ie food comes out but other side is inactive (nothing comes out)
- Usually used to protect a distal anastomosis
v) double barrelled - can be temp with prox and distal opening but seperate tubes
vi) right side of abdo and sticking out of patient (not pressed against skin) > allows liquid stool contents to go into the bag and protect the skin
COLOSTOMY
i) what is it and name three uses
ii) what is found in the bag?
iii) what is a permanent end colostomy? what is it used for (2)
iv) what is a temporary end colostomy? what is it used for (2)
v) what is a loop colostomy
vi) which side of the abdo is it usually found? how is it found in relation to the skin?
i) connection from large bowel
- divert from large bowel obstruc eg tumour, allow bowel to rest due to fistula/perforation/complicated diverticulitis, trauma
ii) solid faeces
iii) used in large resection and if you are unable to join remaining bowel or the patient is not fit for a second operation
iv) used in case pathology needs to settle or the patient needs time to get fitter for the second operation
v) shares a posterior wall to protect from a distal anastomosis
vi) left hand side
_ flushed to the skin and usually more solid in bag
UROSTOMY
i) what are the used after?
ii) what do they do?
iii) what is the ileal conduit?
iv) where are they typically located? what will the bag contain?
i) used after cystectomy (urinary bladder removal)
ii) drain urine from the ureters to the skin and into the stoma bag
iii) ileal conduit = connecttion between the ureters and the skin as its usually made from a piece of ileum
iv) usually located on right iliac fossa and bag will contain urine
STOMA POSITIONING
i) where should it be away from? (3)
ii) which structure can strengthen it?
iii) who helps facilitate this
i) away from site of incision, bony prominences and belt line
ii) strengthed by rectus sheath
iii) stoma nurse
STOMA COMPLICATIONS
i) name four immediate(days)
ii) name four early (weeks)
iii) name four late (months)
iv) name three things that can occur at any and all times
i) GA complications, necrosis, bleeding, retraction, infection
ii) stenosis/obstruction, high output - dehydrat/electrolyte imbalance, retraction, skin irritation, infection
iii) stenosis/obstruc, parastomal hernia, prolapse, fistula format, skin irritation
iv) psychological, infection, retraction
CASE HISTORY - NECROTIC STOMA
i) what is a hartmanns procedure?
ii) what should be done first when a stoma doesnt look right
iii) what can cause a stoma to be necrotic? give reasons (2)
iv) what needs to be done if there is extensive devasc of the small bowel? what if the necrosis is limited to the stoma mucosa?
v) what can this lead to if untreated?
vi) what is a differential for necrotic stoma?
i) resection of the recto-sigmoid colon > form a rectal stump and an end colostomy
ii) ABCDE approach
- take off stoma bag and have a look
iii) insufficient blood supply
- poorly vascularised piece of bowel
- poorly perfused systemically - assess extent of necrosis
iv) if there is extensive devascularisation of small bowel - stoma needs revising
- if necrosis is limited to stoma mucosa > simple observation
v) can lead to future stricture/stenosis
vi) blood blister
CASE HISTORY - CD PATIENT
patient presents with abdo pain and vomiting and stoma not working for 24hrs - crohns ileostomy 1 year ago
i) what should be done first? (2)
ii) what is the first exam that should be done?
iii) what complication of stoma can crohns cause and what can this lead to?
iv) overall what exam and imaging should be done
i) ABCDE and full history
ii) take off stoma and do a digital exam of stoma (stick finger in to see why not working) - if cant get finger in is it stenosed etc
iii) CD can cause transmural inflamm and can lead to stenosis or fistula formation
iv) do full abdo exam and a contrast CT
CASE HISTORY - HIGH OUTPUT STOMA
i) what is a high output stoma?
ii) what is the first thing that should be done for the patient
iii) what things would you be most concerned about? (2)
iv) why may this be happening? what can be given to help
i) too much is coming out into the bag - >500ml in 24hrs
ii) ABCDE approach and full exam
iii) electrolyte disturbance and dehydration
iv) it can take time for body to adjust to a new stoma
- can give loperamide (immodium) to bulk up stool
CASE HISTORY - CHANGE IN STOMA APPEARANCE
i) what is an end colostomy?
ii) what should be done first?
iii) what can cause a change in stoma appearance?
iv) how can this be rectified
i) if parts of large bowel/rectum have been removed and remaining bowel is brought out
ii) ABDCDE > full hx > abdo exam > take off stoma bag > stoma exam
iii) parastomal hernia - another piece of bowel comes through the muscle layer if the muscle hole is too big (to stop ischaemia)
iv) can use a hernia belt or may need to redo the stoma elsewhere in the abdomen
what is this?
parastomal hernia
- bowel has pushed through the muscle hole that has been created for the stoma
PARASTOMAL HERNIA
i) what is it?
ii) give three RFs
iii) what is a complication? what is needed?
i) weakness in abdo wall can lead to protrusion of the bowel
ii) obesity, cough, not fashioning the stoma in the rectus
iii) can become incarcerated/obstruc/strangulated > need repair
- put stoma in a new place
CASE HISTORY
i) what is stoma prolapse/hernation?
ii) how is this managed?
iii) how can a small prolapse be managed? (3)
iv) how can a large prolapse be managed? (2)
i) when stoma herniates out > bowel is external
ii) ABCDE, full exam
iii) sugar (osmotic agent) to reduce oedema then manual reduction of the prolapse and apply a binder
iv) surgical intervention and refashioning of stoma
- also applies of recurrent small prolapse, ischaemic change or mucosal irritation
