INTRODUCTION — Ileostomy or colostomy creation may be required temporarily or permanently for the management of a variety of pathologic conditions, including congenital anomalies, colon obstruction, inflammatory bowel disease, intestinal trauma, or gastrointestinal malignancy [1].
The anatomic location and type of stoma construction have an impact on management. Loop colostomies tend to be larger and somewhat more difficult to manage than end colostomies. The type and volume of output (effluent), and therefore fluid loss, is determined by the location of the stoma relative to the ileocecal valve. Fluid loss is primarily a factor with end or loop ileostomies.
With proper stoma care and attention to nutrition and fluid management, most ostomy patients are able to have full, healthy, active social and professional lives and normal sexual activity. In many cases, quality of life can be improved, even in the context of a permanent ostomy, with treatment of the underlying disease.
The routine care and management of common issues and complications of stoma creation are reviewed here. The types and indications, and principles of ostomy construction and reversal, are discussed separately. (See "Overview of surgical ostomy for fecal diversion" and "Parastomal hernia".)
PATIENT EDUCATION — Patient preparation for adaptation to life with a temporary or permanent ostomy begins in the preoperative period, whenever possible. (See "Overview of surgical ostomy for fecal diversion", section on 'Preparation and counseling'.)
The patient must adapt to new patterns of fecal elimination and to their altered body and image of themselves. Successful adaptation requires the patient to master new skills and to deal effectively with the many emotional issues associated with their altered anatomy and with altered continence. Interventions that promote adaptation include:
●Preoperative stoma site selection by ostomy nurse specialist (enterostomal therapy nurse, wound ostomy continence nurse) or experienced surgeon. Preoperative stoma site marking has been associated with fewer ostomy-related complications (eg, leakage, dermatitis), improved patients' ability to care for the ostomy independently, and reduced health care costs [2]. Position papers by both the American Society of Colon and Rectal Surgeons (ASCRS) and Wound Ostomy Continence Nurse Society (WOCN) have been published to guide proper stoma site markings [3]. (See "Overview of surgical ostomy for fecal diversion", section on 'Site selection and marking'.)
●A strong focus on individualized patient education, with a preoperative and postoperative component [2].
●Supportive counseling for all patients preoperatively and in-depth counseling for any patient who is having trouble adapting [4,5]. A number of studies have demonstrated that involvement of an ostomy nurse specialist has a significant impact on long-term positive outcomes and reduced complication rates, as does involvement in ostomy support groups such as the United Ostomy Association of America [6-11].
POUCH SYSTEMS AND ROUTINE OSTOMY CARE
Pouch systems — The main functions of ostomy pouches are to contain the ostomy effluent, contain odor, and protect the peristomal skin. Many pouching systems are available as either one- or two-piece systems:
●One-piece systems include a protective skin barrier with a tape border fused to an odor-proof pouch.
●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.
One-piece systems 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 have the advantage that the pouch can be replaced without having to remove the protective skin barrier each time.
Pouch placement — The patient should be taught strategies that can help promote pouch adherence to the skin, minimize leakage, and protect peristomal skin. These include:
●Selecting a pouching system that conforms to the abdominal contour at the stoma location. As examples:
•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 [12].
•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. (See 'Stomal prolapse' below.)
•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 caregivers 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) [6,13].
●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.
Pouch emptying and care — Odor and gas are common concerns for any individual with an ostomy [14]. 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. These include the following:
●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 odor is a particular concern for the patient, bismuth subgallate or chlorophyllin copper complex effectively reduces stool odor when taken routinely [6].
●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.
DIET AND CONTROL OF GAS — Many patients assume that they will have to adhere to a special diet because of their ostomy. Dietary modifications are usually minimal, but specific foods can influence the amount of the gas and the consistency and odor of the effluent [6,15]. Patients should be given a general list of gas-producing foods (table 1). 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 gas-producing 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 [6]. (See "Patient education: Gas and bloating (Beyond the Basics)".)
ILEOSTOMY PATIENTS — The type and volume of output (effluent), and therefore fluid loss, is determined by the 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 [6,13].
Dehydration — Dehydration affects up to 30 percent of patients after loop ileostomy creation and is the most common cause for hospital readmission after ileostomy surgery [16,17].
How much fluid should an adult drink each day to prevent dehydration? It is a simple question with no easy answer, as studies have produced varying recommendations. As examples:
●The United States National Academies of Sciences, Engineering, and Medicine (formerly the Institute of Medicine) have recommended adequate intake (AI) values for total water at levels to prevent dehydration [18]. The AI for men aged 19+ is 3.7 liters each day, 3 liters (13 cups) of which should be consumed as beverages. The AI for women aged 19+ is 2.7 liters, about 2.2 liters (9 cups) of which should be consumed as beverages each day.
●The Eatwell guide of the British National Health Service (NHS) has recommended drinking six to eight cups or glasses of fluid a day [19]. Each cup or glass generally contains eight ounces of fluid. Thus, eight cups of fluid would add up to 64 ounces or approximately 1.9 liters.
Regardless, patients with an ileostomy should be instructed to increase their daily fluid intake beyond the recommended AI 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 [20]. 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 [6,21]. (See "Etiology, clinical manifestations, and diagnosis of volume depletion in adults".)
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 their caretakers in stoma care; postdischarge counseling; and tracking of intake and output has effectively reduced hospital readmission while maintaining an appropriate hospital length of stay [22].
High ostomy output — First-line management of patients with elevated ileostomy output (defined as >1.5 L/day) should include soluble viscous, nonfermenting, gel-forming fiber supplementation (eg, psyllium husk), which can slow transit time by absorbing water and forming a gel-like consistency [23-25]. Patients may slowly increase supplementation up to four times daily and also at double doses. By contrast, insoluble fiber supplements (eg, Wheat Bran), also referred to as bulk-forming laxatives, can speed up transit time and are primarily used to treat constipation.
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 (table 2)). We usually start with loperamide because it is over the counter and has fewer side effects [26]. 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. Occasionally, patients may require intravenous fluid hydration as outpatients to compensate for the fluid losses. The efficacy of the different management strategies for high ostomy output is discussed in detail separately. (See "Enterocutaneous and enteroatmospheric fistulas", section on 'Fistula output reduction'.)
Rarely, patients with difficult-to-control ileostomy output may need to be maintained on intravenous 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.
Food blockage — Ileostomy patients should also be taught strategies to prevent food blockage proximal to the ostomy site, which can occur because the ileal lumen is <1 inch (2.5 cm) in diameter. There is also the potential for further narrowing at the point where the bowel passes through the fascia/muscle layer. If the patient consumes large amounts of insoluble fiber, the undigested fiber may create an obstructing mass (bezoar). Common "offenders" include popcorn, coconut, mushrooms, black olives, stringy vegetables, corn, nuts, celery, foods with skins, dried fruits, and meats with casings.
Food blockage is easily prevented by instructing the patient to consume potential offenders one at a time in small amounts, to chew thoroughly, and to monitor their response [6,21].
Drug malabsorption — Because the small bowel is the most important site of drug absorption, patients with ileostomy are at risk for suboptimal drug absorption. The patient with an ileostomy must be taught to take medications in dosage forms of quick dissolution, such as liquids, gelatin capsules, and uncoated tablets, and avoid time-released and enteric-coated medications as well as very large tablets since these forms of medication are likely to be incompletely absorbed. Consult with a pharmacist regarding medications that may not dissolve or be absorbed appropriately. They must also avoid laxatives due to the risk for acute dehydration [6].
COLOSTOMY PATIENTS — Descending/sigmoid colostomies produce stool that is formed and does not contain digestive enzymes. Colostomy patients can be reassured that there are no absolute dietary restrictions [27]. However, they should be encouraged to ingest sufficient fiber and fluids to prevent constipation and should also be counseled regarding gas-producing foods and lag time. (See 'Diet and control of gas' above.)
Patients should be taught to prevent constipation by maintaining appropriate fiber (20 to 35 g/day) and fluid intake (at least 1.5 to 2 L/day). If constipation does occur, it can be managed with laxatives or irrigation. (See "Management of chronic constipation in adults", section on 'Fiber' and 'Colon irrigation' below.)
For severe constipation, digital disimpaction of the colostomy may be necessary but should only be performed by an experienced clinician or ostomy nurse.
The patient should also be informed that intermittent mucoid discharge is normal either from the distal ostomy site (mucus fistula) or from the anus with ostomies that have a defunctionalized distal limb.
Colon irrigation — Routine irrigation is appropriate only for patients with distal colostomies and is not effective for all patients. Irrigation involves instillation of 500 to 1500 mL of tap water into the descending or sigmoid colon ostomy on a routine schedule (usually daily or every other day); the resulting bowel distention stimulates peristaltic activity, which causes the distal colon to empty.
Patients who had fairly normal bowel elimination patterns preoperatively can usually achieve complete evacuation of the colon with irrigation, which provides them with a "stool-free" interval of approximately 24 hours. Most patients who manage their colostomies with routine irrigation are essentially continent and need to wear only a small pouch or "cap" for collection of mucous and deodorization of flatus. Patients who manage effectively with routine irrigation report a higher quality of life than patients who manage with pouching [6,28-30]. Some have raised concerns that routine irrigation could result in bowel dependence, but colonic distention is a normal physiologic stimulus to effect evacuation, and no studies or data have indicated any adverse effects.
Colonic irrigation is also used to prevent low anterior resection syndrome in patients with a protective stoma. (See "Low anterior resection syndrome (LARS)", section on 'Prevention'.)
PHYSICAL ACTIVITY — A common concern for many patients is the impact of the stoma on activities of daily living. The patient can be reassured that most activities can be safely resumed with minimal, if any, modifications. As an example, bathing and showering can be performed with the pouch on or off, and clothing modifications are generally not required. Most sports activities can be resumed as well, with the exception of extreme contact sports, which could potentially damage the stoma. The addition of a belt or binder is helpful in maintaining a pouch seal during vigorous activity and with perspiration [6].
Sex — Sexual activity is a particular concern for many patients with an ostomy. Patient counseling should address questions regarding sexual activity and partner response [31]. The ostomy does not affect organic sexual function. However, if the ostomy was placed due to some form of pelvic surgery or prior radiation treatment, it is possible that the autonomic nerves controlling sexual function, which are located adjacent the rectum and the pelvic sidewall, may have been injured. (See "Overview of sexual dysfunction in females: Epidemiology, risk factors, and evaluation" and "Epidemiology and etiologies of male sexual dysfunction".)
It is helpful for the patient to empty the pouch and assure an intact pouch seal before engaging in sexual activity. In addition, many patients and their partners find it helpful to use lingerie or a cummerbund to conceal and secure the pouch. Commercial pouch covers, lingerie, and undergarments specifically designed for ostomates are available.
Travel — Patients who are traveling should be advised to:
●Take extra ostomy supplies, and if flying, place them in carry-on luggage.
●Some airports offer private pre-screenings upon request.
●Avoid exposing ostomy pouches and adhesive adjuncts to extreme temperatures, which may alter the adhesive quality.
●Drink only bottled water if local tap water is not known to be safe [6].
OSTOMY COMPLICATIONS — The incidence of stomal complications ranges from 14 to 79 percent [32-40]; nearly half of all stomas eventually become "problematic" due to pouching and peristomal skin issues [12,32,41,42].
Complications vary with the type of ostomy, with lower complication rates for those with end colostomies and end ileostomies [37,43]. Loop ileostomies have the highest complication rates [38,39,41]. The most common problems of end and loop ileostomies are dehydration and skin irritation (related to the high-output, high alkaline enzymatic effluent) and small bowel obstruction. Although prolapse can occur in all types of stomas, it is more prevalent in loop colostomies, particularly those constructed using the transverse colon [37,44]. Parastomal hernia and retraction are the most common complications for end and loop ileostomies and colostomies [37,44,45]. (See "Parastomal hernia".)
Stomal and peristomal complications can occur in the early postoperative period or many years following stomal construction [8,32,37,41,43-51]. Although profiles of early and late ostomy complications do overlap (eg, stomas can retract early or late), they are often quite different [12]:
Very early complications (days) — Complications that occur very early in the postoperative course (days) are often related to technical issues [39,41] and often require return to the operating room. Examples include large bowel obstruction due to a twist in the bowel leading to the stoma.
Early complications (<3 months) — Early complications, defined as those occurring within three months of stoma construction, are often related to suboptimal stoma site selection [8,38] but are heavily influenced by patient factors (eg, old age, poor nutritional status, higher American Society of Anesthesiologists [ASA] class, comorbidities, obesity, tobacco use, and underlying malignancy) [12,32,41].
Early complications include stomal ischemia/necrosis, stomal bleeding, stomal retraction, and mucocutaneous separation.
Stomal necrosis — The incidence of stomal necrosis in the immediate postoperative period is as high as 14 percent [32,52]. Adequate mobilization of the bowel, preservation of the blood supply to the stoma, and an adequate trephine size are important factors for avoiding this complication. (See "Overview of surgical ostomy for fecal diversion", section on 'Ostomy construction'.)
Independent risk factors for stomal necrosis include emergency surgery, obesity, and inflammatory bowel disease, in particular Crohn disease [49].
Stomal necrosis most commonly occurs in the early postoperative period as a result of venous congestion or arterial insufficiency (eg, tight fascial opening, excessive mesenteric stripping). The most critical assessment is to determine the extent of necrosis, which can be performed by inserting a lubricated test tube into the stoma and using a flashlight to visualize the proximal mucosa. An alternative is to use a flexible sigmoidoscope or a lighted anoscope. Management is based upon the clinical scenario:
●If the necrosis extends to the proximal bowel below the anterior fascia, immediate revision is required.
●If the proximal bowel is viable and the necrosis is limited to the stoma (superficial to the anterior fascia), observation may be appropriate.
•If necrosis progresses, a revision is required.
•If sloughing occurs, only gentle debridement may be necessary. Sloughing of the stoma can result in stomal retraction and pouching challenges but may not require surgical intervention.
In acute settings, stoma ischemia is more often than not limited to the mucosa above the fascia and thus can be observed, albeit with a possible resultant stricture in the future [53].
Stomal bleeding — Major bleeding from the stoma (as opposed to a gastrointestinal bleed) is uncommon and usually indicates either a stomal laceration from a poorly fitting appliance or the presence of peristomal varices in the patient with portal hypertension. Minor bleeding from the stoma can also occur early in the postoperative period related to creation of the stoma or later with overly vigorous stomal cleansing. Initial management of stomal bleeding involves direct pressure and local cauterization (handheld cautery, silver nitrate) or suturing of the bleeding vessel, if easily identified.
Peristomal varices are most frequently seen in patients who underwent a colectomy for ulcerative colitis in the setting of primary sclerosing cholangitis. Peristomal varices can also develop in patients with other causes of portal hypertension. Initial management consists of direct pressure followed by injection sclerotherapy or direct suture. However, recurrence is frequent, and medical therapy or intervention (eg, transjugular intrahepatic portosystemic shunting) may be needed to reduce portal pressures [54-57]. (See "Overview of transjugular intrahepatic portosystemic shunts (TIPS)".)
Stomal retraction — Stomal retraction is defined as a stoma that is 0.5 cm or more below the skin surface within six weeks of construction, typically as a result of tension on the stoma (picture 1) [32,38]. Stomal retraction leads to leakage and difficulties with pouch adherence, resulting in peristomal skin irritation. The incidence of stomal retraction ranges between 1 and 40 percent [32,38,41,52].
The most common risk factors are obesity, due to the thickness of the abdominal wall and foreshortened mesentery, and initial stoma height <10 mm [41]. Proper stoma height and minimizing tension are important factors for preventing this complication. (See "Overview of surgical ostomy for fecal diversion", section on 'Ostomy construction'.)
Management also depends upon the clinical scenario:
●If the stoma retracts below the fascia, immediate operative revision is required to prevent intra-abdominal contamination from the stoma output [12].
●A stoma that has retracted but stays above the fascia can be managed with local wound care, a convex pouching system, and the use of a belt or binder. If these measures fail to provide a secure pouch seal, surgical revision may be needed. However, revision is appropriate only when an improved outcome can be expected and is not appropriate when the cause of the problem has not been addressed [7,54]. Approximately 1 percent of patients experience stomal retraction as a result of postoperative weight gain. Overweight patients should be encouraged and assisted to lose weight prior to surgical revision.
●If nonoperative management of a retracted stoma fails, operative revision or re-siting of the stoma is necessary. Re-siting the stoma to the upper abdominal wall, which is usually thinner, may be helpful.
Mucocutaneous separation — Mucocutaneous separation refers to the separation of the ostomy from the peristomal skin. Mucocutaneous separation results in leakage and skin irritation. It occurs in 12 to 24 percent of patients early in the postoperative period [32,41]. The best approach to preventing this complication is meticulous technique when approximating the bowel to the skin. (See "Overview of surgical ostomy for fecal diversion", section on 'Ostomy construction and maturation'.)
Mucocutaneous separation can be partial or circumferential; if circumferential, stomal stenosis can occur as the tissues heal by secondary intention. (See 'Stomal stenosis' below.)
Circumferential separation of the suture line with retraction of the stoma should be revised immediately. For less severe separations, the defect can be filled with absorptive material, such as calcium alginate, skin barrier powder, paste, or hydrofiber. Covering the area with the skin protective barrier with a barrier ring will help protect the wound from effluent and facilitate healing.
Late complications (>3 months) — Late stomal complications are generally described for permanent ostomies since many temporary stomas are reversed within three months [58]. Risk factors for late complications include duration of stoma, increases in intra-abdominal pressure (obesity, chronic obstructive pulmonary disease), emergency surgery [32,41,52], inadequate mobilization of the bowel with resultant height of stoma <10 mm, and inappropriately sized aperture [12,32].
The most common late complications include parastomal hernia, stomal prolapse, and stoma stenosis [38]. A closed stoma site following ostomy reversal can also be associated with complications such as wound infection, delayed healing, and hernia formation.
Parastomal hernia — Parastomal hernia formation is a common complication, especially among colostomy patients. Risk factors include obesity and poor abdominal muscle tone, conditions producing a chronic cough, placement of the stoma outside of the rectus muscle, and a large fascial opening. (See "Parastomal hernia", section on 'Risk factors'.)
Most parastomal hernias are asymptomatic and do not progress to complications (eg, incarceration, strangulation, bowel obstruction) [54]. The diagnosis and management of parastomal hernia is discussed separately. (See "Parastomal hernia", section on 'Indications for hernia repair' and "Parastomal hernia", section on 'Surgical approach'.)
Stomal prolapse — Prolapse is the telescoping of the intestine out from the stoma and can occur with any type of stoma. Prolapse can make appliance placement and adherence difficult, and prolonged prolapse causes intestinal edema and, if significant, can lead to intestinal incarceration or strangulation.
The incidence ranges from 7 to 26 percent, with the highest rates associated with a loop transverse colostomy and end descending colostomies [32,37,52,58,59]. Risk factors for prolapse may include a large abdominal trephine, increased intra-abdominal pressure, and a redundant loop of bowel proximal to the stoma [38]. Alternative fixation techniques during ostomy construction have been proposed to prevent prolapse [35,43,60,61]. However, there are no data to support these approaches. (See "Overview of surgical ostomy for fecal diversion", section on 'Other sites of fixation'.)
Uncomplicated prolapse can be managed conservatively with cool compresses and/or application of an osmotic agent (eg, table sugar or honey) to reduce edema, followed by manual reduction of the prolapse and application of a binder with a prolapse over-belt to keep the bowel recued into the abdomen, or by pouching modifications to accommodate the prolapsed bowel when reduction cannot be established or maintained [26,62]. Manual reduction should be initiated at the very tip of the prolapse (beehive) or lumen, and then gentle, slow invagination should proceed. In this way, the prolapsed bowel will intussuscept back into the abdomen.
Complicated prolapse or prolapse producing ischemic changes or severe mucosal irritation and bleeding usually requires surgical intervention. Local revision of the prolapse is accomplished by performing a full-thickness resection of the prolapsed intestinal segment with construction of the stoma at the original site. In the event of a further recurrence, additional bowel resection and relocation of the stoma may be necessary [38].
Stomal stenosis — Stomal stenosis refers to a narrowing of the stoma sufficient to interfere with normal function. The incidence ranges from 2 to 15 percent and is more common with an end colostomy [38,63,64].
Stomal stenosis can occur in the early postoperative period but is more likely to develop months later. Early stenosis of ileostomy, due to edema at the fascial and more superficial levels (assuming appropriate skin opening), can be conservatively managed with gentle insertion of a large, 36 French soft-tipped Foley bladder catheter just proximal to the fascial level. The balloon should not be inflated. If there is significant resistance upon intubation of the stoma, the procedure should be abandoned. Care must be taken to avoid perforation. Stenosis can occur later at the skin or the fascia level or stoma outlet secondary due to scarring or tightness of the mucocutaneous junction. Stenosis may be attributable to peristomal sepsis, retraction, an ill-fitting pouching system, or suboptimal surgical technique. The patient should be evaluated for other processes that could contribute (eg, Crohn disease, primary or recurrent malignancy).
Mild stenosis may be identified only by digital examination of the stoma, with few symptoms, and can usually be managed by dietary modifications (eg, avoidance of insoluble fiber); gentle routine dilatation of the stoma may also be helpful but is not evidence based.
Clinically significant stenosis usually causes cramping pain followed by explosive output and usually requires surgical correction [7,54]. For these, local revision may be preferred over dilation, which can be complicated by peristomal bleeding, tissue injury, fibrosis, and further stenosis. Local repair involves excision of scar tissue with adequate mobilization and creation of a new tension-free stoma at a new or relocated site. Enlargement of the skin opening via a double Z-plasty technique may be useful in some situations (eg, limited number of sites for ostomy relocation, limited scarring) [65].
Peristomal skin problems (any time) — The most common ostomy complication is peristomal skin breakdown, with varying severities from minor skin trauma, to dermatitis, to ulceration, to pyoderma gangrenosum (in Crohn patients). Peristomal skin breakdown can occur early or late and is more prevalent with ileostomies than colostomies.
Mechanical trauma — Mechanical trauma typically presents as patchy areas of irritated, denuded skin that result from repeated removal of adhesive products or overly aggressive cleansing techniques.
Patients with peristomal hair should be taught to clip the hair to prevent mechanical trauma to the hair follicles. Patients should be taught to use plasticizing skin sealants to help prevent skin damage (skin sealants are optional and specific to manufacturer) with pouch removal and should be cautioned to use a gentle technique when cleaning the peristomal skin. (See 'Pouch systems and routine ostomy care' above.)
Treatment involves elimination of the causative factors and application of skin barrier powder to the involved areas, followed by blotting with a skin sealant or moistened finger to provide a nonpowdery pouching surface [6,7,54].
Dermatitis — Peristomal skin irritation is more common for patients with an ileostomy due to the nature of the effluent (picture 2). It is characterized by severely denuded skin along the inferior aspect of the stoma. Creating a protuberant spout for the ileostomy approximately 2 to 3 cm high to optimize pouch fit is the best method to minimize contact of effluent with the skin [2]. (See "Overview of surgical ostomy for fecal diversion", section on 'Ostomy construction and maturation'.)
Peristomal skin irritation can also result from mechanical trauma, an allergic reaction to a pouching product, or peristomal fungal infection, which is more common in warm and humid climates or related to antibiotic therapy [38]. Fungal infections present as a maculopapular rash with distinct satellite lesions (picture 3).
Allergic reactions can occur with any of the products used to protect the peristomal skin or to assure adhesion of the pouching system; allergic reactions are characterized by pruritus, erythema, and blistering in the area corresponding to and demarcated by contact with the offending agent (picture 4).
Treatment involves identification and correction of the causative factors, elimination of any allergens, and treatment of the denuded areas with skin barrier powder or antifungal powder (eg, nystatin or miconazole). If necessary, the powder can be lightly blotted with a moist finger or skin sealant to assure a pouchable surface [6,7,54,66]. Topical steroids may sometimes be required for a severe reaction [6,7,54].
Whenever possible, the patient with peristomal skin problems should be seen by an ostomy nurse specialist. Refractory peristomal skin breakdown should prompt a referral to a surgeon with experience and expertise in stoma management. As an example, for patients who experience weight or body habitus changes after the stoma is created, fat grafting, focus liposuction, scar release, or excision of redundant skin by a plastic surgeon may help with pouching and alleviate peristomal skin problems [67].
Parastomal ulceration — Parastomal ulceration, defined as discontinuity of peristomal skin with adjacent inflammation, is usually the result of an infected postoperative hematoma or intestinal fistula [38].
Granulomas — Granulomas are red, moist, elevated lesions at the mucocutaneous border. Often they are a result of retained suture or other extraneous material. Granulomas bleed easily and may be tender. They may become infected. Maintaining barrier seals can be a problem. Treatment consists of examining and removing any extraneous material and eliminating the lesion. Silver nitrate should be applied to remove the elevated tissue. Several treatments may be necessary. After treatment and until healed, the area should be crusted with barrier powder and a skin sealant. If extensive, the pouching system may need to be adjusted until the area heals. Failure of lesions to heal or frequent reoccurrence should be evaluated for other pathology [68].
Peristomal pyoderma gangrenosum — Pyoderma gangrenosum (PG) is a neutrophilic dermatosis with unclear etiology. Peristomal pyoderma gangrenosum (PPG) is a subtype of PG that occurs at the stoma site typically in patients with inflammatory bowel disease (IBD) [69]. PPG occurs in 0.5 to 1.5 per million people annually, which accounts for 15 percent of PG cases [70]. (See "Pyoderma gangrenosum: Pathogenesis, clinical features, and diagnosis" and "Dermatologic and ocular manifestations of inflammatory bowel disease".)
According to a 2019 systematic review (79 studies; 335 cases), most PPG patients are female (67 percent), with a mean age of 48 years and a diagnosis of IBD (81 percent; Crohn disease 50 percent, ulcerative colitis 31 percent) [70]. PPG has also been identified in patients with intra-abdominal malignancies [71]. Ileostomies, colostomies, and other stomas (urostomies) are involved in 78, 16, and 6 percent of patients.
PPG can develop within weeks to years after stoma construction, with an incidence of <1 percent of stomas (2 to 4 percent in those with IBD) [70-74]. Sixty-nine percent of patients reported an IBD flare with the onset of PPG [70]. The lesions typically present as full-thickness ulcers, and pain and pathergy are dominant characteristics (picture 5).
The diagnosis of PPG is clinical and usually one of exclusion since there is no definitive diagnostic test. The lesion is frequently misdiagnosed as a stitch abscess, contact dermatitis, urinary or fecal fistula, an extension of Crohn disease, or a wound infection. Patients with suspected PPG should be referred to a dermatologist for possible biopsy.
Biopsy of the skin lesion is nondiagnostic but does help to exclude certain pathologies (eg, cancer, Crohn disease) [71]. If a skin biopsy is performed to rule out other pathology, acute and chronic inflammation is the typical finding. The biopsy should be performed with caution as this may increase the size of the wound. Granulomas may be noted on microscopic examination. Biopsies should be performed at the leading edge of the ulceration with 4 to 6 mm punch biopsies. Similarly, cultures should also be obtained to evaluate for any infectious etiologies; PPG ulcers are sterile or grow commensal skin or gut flora.
Selecting an unaffected segment of bowel for the stoma is the best way to prevent this complication. However, once occurring, these lesions are managed by systemic, intralesional, and/or topical anti-inflammatory agents, depending on severity [70] (see "Pyoderma gangrenosum: Treatment and prognosis"):
●Mild cases of PPG without active systemic disease can be managed with topical agents. Topical therapies for PPG include corticosteroids and calcineurin inhibitors (eg, tacrolimus) with similar clinical efficacies (62 versus 56 percent). Intralesional injection of corticosteroids is less effective and in some cases worsened PPG.
●More severe or rapidly evolving cases of PPG require systemic medication or even surgical intervention. Corticosteroids are the most commonly used systemic treatment, with a complete response rate of 52 percent in 146 patients. Other systemic options with a similar (50 percent) response rate include cyclosporine and dapsone. Systemic metronidazole, azathioprine, sulfasalazine, and tacrolimus are less commonly used. Tumor necrosis factor alpha inhibitors such as infliximab and adalimumab are favorable therapeutic options for PPG concomitant with active IBD and can be used for refractory PPG regardless of whether IBD is present.
●Wound care is critical for PPG management. The overall goals are to provide a clean wound environment, absorb exudate, maintain moisture, and prevent further skin damage [75]. Care must be taken to minimize trauma since pathergy is a prominent feature of these lesions. Dressings should be nonadherent, and stoma management should be modified to minimize trauma to the affected area [54,76].
Surgical management may be required for intractability (most common), severe colitis, or complications (eg, perforation, stenosis, obstruction, herniation). The success rate depends on surgical technique [70]:
●Stoma closure or resection of bowel with active IBD completely healed PPG with few recurrences in small case series.
●Stoma relocation resolved PPG in almost all patients, but 67 percent recurred at the new stoma location.
●Wound debridement was less effective, associated with only 26 percent complete response.
Continent ileostomy complications
Nipple valve slippage — Patients with a Kock pouch or Barnett continent ileostomy reservoir can develop nipple valve slippage, which presents as obstruction or inability to appropriately intubate and evacuate intestinal contents. (See "Overview of surgical ostomy for fecal diversion", section on 'Continent ileostomy'.)
Surgical management is indicated. Revision may be possible; however, some situations require a resection and reconstruction of a new continent-type ileostomy or end-ileostomy.
SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Parastomal hernia".)
INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5th to 6th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.
Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)
●Basics topics (see "Patient education: Colostomy care (The Basics)" and "Patient education: Colectomy (The Basics)" and "Patient education: Ileostomy care (The Basics)")
SUMMARY AND RECOMMENDATIONS
●Fecal diversions may be required on either a temporary or permanent basis. Fecal diversions are commonly classified according to the segment of the bowel used (eg, colon, small bowel) and/or surgical construction (eg, loop, end). Location and construction have an impact on routine management and the frequency and types of complications. (See 'Introduction' above and "Overview of surgical ostomy for fecal diversion", section on 'Fecal diversions'.)
●Patients with a colostomy or an ileostomy must adapt to a significant alteration in body image as well as challenges related to odor and gas management, sexual activity, traveling, and dietary limitations. A nurse who specializes in the management of ostomies (eg, enterostomal therapy nurse, wound ostomy continence nurse) can provide advice to the patient regarding the daily management of an ostomy as well as fit the patient with an appropriately sized pouch system. The patient can be reassured that most activities, including daily living, sex, sports, and travel, can be safely resumed with minimal, if any, modifications. (See 'Patient education' above and 'Pouch systems and routine ostomy care' above and 'Physical activity' above.)
●Specific foods can influence the amount of the gas and the consistency and odor of the effluent (table 1). Dietary modifications and over-the-counter gas-reducing agents (eg, Beano and Gas-X) help reduce the volume of gas. Other strategies to control gas include "muffling" measures, "venting" strategies, and measures that affect the "timing" of flatulence. The usual "lag time" between ingestion of a gas-producing food and actual flatulence is between two and four hours for ileostomy and six to eight hours for distal colostomy. (See 'Diet and control of gas' above.)
●Patients with ileostomies or ascending or transverse colostomies should be taught to (see 'Ileostomy patients' above):
•Increase daily fluid intake by 500 to 750 mL beyond the recommended average intake for the general population to prevent dehydration or electrolyte imbalance. (See 'Dehydration' above.)
•Take soluble fiber supplements or antimotility agents for persistent high ostomy output (>1.5 L/day). (See 'High ostomy output' above.)
•Consume small quantities of food items with high insoluble fiber content to prevent food blockage proximal to the stoma. (See 'Food blockage' above.)
•Take medications in dosage forms of quick dissolution (eg, liquids, gelatin capsules, and uncoated tablets) and avoid time-released and enteric-coated medications, as well as very large tablets, to avoid drug malabsorption. (See 'Drug malabsorption' above.)
●Although there are no absolute dietary restrictions for descending or sigmoid colostomy patients, patients should be encouraged to ingest sufficient fiber (20 to 35 g/day) and fluids (at least 1.5 to 2 L/day) to prevent constipation. If constipation does occur, it can be managed with laxatives, stoma disimpaction, or colonic irrigation (for distal colostomy patients only). (See 'Colostomy patients' above.)
●Nearly half of all stomas eventually become "problematic" due to pouching and peristomal skin issues. Complications vary with type of ostomy (loop>end; ileostomy>colostomy) and the time from construction (see 'Ostomy complications' above):
•Early (<3 months) complications include stomal ischemia/necrosis, stomal bleeding, stomal retraction, and mucocutaneous separation. (See 'Early complications (<3 months)' above.)
•Late (>3 months) complications include parastomal hernia, stomal prolapse, and stoma stenosis. (See 'Late complications (>3 months)' above.)
•Peristomal skin breakdown, which can vary in severity from minor skin trauma, to dermatitis, to ulceration, to granulomas, and to pyoderma gangrenosum (in inflammatory bowel disease or cancer patients), can occur early or late and is more prevalent with ileostomies than colostomies due to the high-volume, high-alkaline enzymatic output of ileostomies. (See 'Peristomal skin problems (any time)' above.)
●A surgical revision of an ostomy may be necessary when an ostomy becomes dysfunctional, such as in cases of symptomatic parastomal herniation, severe stomal stenosis, or stomal ischemia or retraction to below the fascia. (See 'Ostomy complications' above and "Parastomal hernia".)
ACKNOWLEDGMENT — The UpToDate editorial staff acknowledges Dorothy Doughty, MN, RN, CWOCN, FAAN, who contributed to earlier versions of this topic review.
