Patients with Ileostomy (Landmann, 2024)

• Instruct the patient to increase daily fluid intake by 500 to 750 mL to prevent dehydration.
  • Average ileostomy output ranges from 500 mL to 1300 mL per day, with up to 1800 mL in early postoperative period.
  • Effluent contains large amounts of sodium and potassium.
  • Inform patient to increase oral fluid intake if experiencing high-volume output or heavy sweating.
  • Recommend water, broth, vegetable juices, and pediatric electrolyte solutions. Discourage the use of sports drinks as some may not be absorbed.
• Instruct patients on the following:
  • A proximal ileostomy may reduce absorption of vitamins, minerals, and electrolytes.
  • Avoid time-release, enteric-coated medications, and large tablets, as they may not be absorbed completely.
  • Refrain from laxative use due to the risk for dehydration.
  • Be alert for signs of fluid-electrolyte imbalance, such as dry mouth, reduced urine output, dark concentrated urine, dizziness on standing, increased fatigue, and abdominal cramping.
  • Avoid large amounts of insoluble fiber which could cause an obstruction.
  • Manage increased ileostomy output with a soluble fiber supplement which can be slowly increased up to four times daily.
  • Manage excessive and inappropriate output with antimotility agents which should be added one at a time and titrated slowly to avoid paralytic ileus or obstruction.

Patients with Colostomy (Landmann, 2024)

• Patients should be encouraged to increase fiber and fluid intake to prevent constipation.
• Inform patients that intermittent mucoid discharge is normal.
• Constipation may be managed with laxatives or irrigation. For severe constipation, digital disimpaction may be performed only by an experienced ostomy nurse or physician.
• Routine colon irrigation is only appropriate for distal colostomy patients; 500 to 1500 mL of tap water is instilled in the descending or sigmoid colon ostomy, daily or every other day, thus stimulating peristalsis causing the distal colon to empty.
• Most physical activities can be resumed, except for extreme contact sports.
• Counsel patients on resuming sexual activity. If an ostomy was placed secondary to pelvic surgery or radiation treatment, the autonomic nerves controlling sexual function may be injured.
• When traveling, patients should pack extra ostomy supplies, avoid extreme temperatures, and drink only bottled water if tap water is not safe to consume.

Complications (Landmann, 2024)

The incidence of stomal complications range from 14 to 79%. Almost half of all stomas eventually become a problem due to pouching and perstomal skin issues. Very early complications that occur within days of surgery may be related to technical issues and frequently require a return to the operating room.
 
Early Complications (within 3 months of surgery)
This is usally related to suboptimal stoma site selection but is heavily influenced by patient factors including age, obesity, poor nutrition, tobacco use, comorbidities, and underlying malignancy.

• Stomal necrosis
  • Characterized by dark brown to black stoma coloration.
  • Management includes observation or surgical revision.
• Stomal bleeding
  • Minor bleeding is normal in the immediate postoperative period and may result from “vigorous” stoma cleaning.
  • Management
    • Direct pressure
    • Local cauterization (cautery, silver nitrate)
    • Suture bleeding vessel, if possible.
• Stomal retraction
  • Stomal retraction refers to a stoma that is 0.5 cm or more below the skin surface within 6 weeks of surgery, often resulting from tension on the stoma.
  • Management
    • Administer local wound care.
    • Use a convex pouch system and belt or binder.
    • Surgical revision may be needed if stoma retracts below the fascia.
• Mucocutaneous separation
  • This is separation of the ostomy from the peristomal skin, often resulting in leakage and skin irritation; may be partial or circumferential.
  • Circumferential separation with retraction of the stoma requires surgical revision immediately.
  • For less severe separation, absorptive material such as calcium alginate, skin barrier powder, paste or hydrofiber can fill the defect; cover the area with a skin protective barrier.

 
Late Complications (3 months or more after surgery)

• Parastomal hernia may occur due to obesity, poor abdominal muscle tone, chronic cough, placement of the stoma outside of the rectus muscle, and a large fascial opening.
• Stomal prolapse is telescoping of the intestine out from the stoma, which can make pouch placement and adherence difficult. Prolonged prolapse can cause intestinal edema and may lead to constriction of the bowel lumen.
  • Uncomplicated prolapse can be managed with cool compresses and/or osmotic agents (e.g., table sugar or honey) to reduce edema, followed by manual reduction of the prolapse (by a trained health care professional) and application of a binder.
  • Complicated prolapse with ischemia or severe mucosal irritation and bleeding requires surgical intervention.
• Stomal stenosis is narrowing of the stoma opening and causes dysfunction; it’s common with end-colostomies.
  • Early stenosis may be conservatively managed by gentle catheter dilation (not inflation) performed by an experienced practitioner.
  • Mild stenosis may be managed with diet modifications (e.g., avoid insoluble fiber).
  • Significant stenosis causes cramps and explosive output, and usually requires surgery.

 
Peristomal Skin Problems
Peristomal skin problems are more prevalent with ileostomies than colostomies.

• Mechanical trauma
  • Appear as patchy areas of irritated, denuded skin resulting from repeated removal of adhesive products and aggressive cleaning techniques.
  • Instruct patients to use plasticizing skin sealants to prevent skin damage with pouch removal, and to gently clean the peristomal skin.
  • Eliminate the causative factors, apply skin barrier powder, and then blot with a skin sealant.
• Dermatitis from peristomal skin irritation
  • May result from mechanical trauma, an allergic reaction to a pouch or adhesive product, peristomal fungal infection, or antibiotic therapy. Allergic reactions are characterized by pruritis, erythema, and/or blistering.
  • Refer patients with peristomal skin problems to an ostomy nurse specialist.
  • Treatment
    • If necessary, remeasure the stoma to ensure a proper skin barrier fit.
    • Identify and correct the causative factors.
    • Eliminate allergens.
    • Treat affected areas with skin barrier powder or antifungal powder.
    • Topical steroids may be required for severe reactions.
• Parastomal pyoderma gangrenosum (PPG)
  • Uncommon ulcerative condition seen with inflammatory bowel disease, Crohn’s disease, and intraabdominal malignancy.
  • PPG may develop within weeks to years after stoma surgery.
  • PPG presents as painful, full thickness ulcers.
  • Obtain cultures from the ostomy to assess for infection.
  • Manage with systemic, intralesional, topical anti-inflammatory agents (e.g., corticosteroids and calcineurin inhibitors) or tumor necrosis factor alpha inhibitors, (e.g., infliximab and adalimumab).
  • Wound care is important; apply nonadherent dressings that absorb exudate, maintain moisture, and prevent further skin damage.
  • Surgical management may be needed for wound debridement, stoma closure or stoma relocation.

Ostomy Reversal (Francone, 2023)

Colostomy closure can occur when the underlying condition has resolved, the patient’s health is fully recovered to baseline, and inflammation has subsided (can take three to six months or more.) Ileostomy closure can be performed between eight weeks and three months following the initial procedure once the anastomosis is healed. Ostomy closure is usually performed locally by freeing the stoma circumferentially from the abdominal wall and using a stapler to create a side-to-side functional end-to-end anastomosis. If this is not feasible, then a handsewn anastomosis may be performed.