Ileostomy Patients (Landmann, 2020)

• 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.
• Patients with a proximal ileostomy may experience poor absorption of vitamins, minerals, and electrolytes.
• Instruct patients to avoid time-released, enteric-coated medications, and large tablets, as they may not be absorbed completely.
• Instruct patients to avoid laxative use due to the risk for dehydration.
• Teach patients the signs and symptoms of fluid-electrolyte imbalance, such as dry mouth, reduced urine output, dark concentrated urine, dizziness on standing, increased fatigue, and abdominal cramping.
• Educate patients to avoid large amounts of insoluble fiber which could cause an obstruction, and to avoid foods such as popcorn, coconut, mushrooms, black olives, stringy vegetables, foods with skins, dried fruits, and meats with casings. These foods should be consumed one at a time, in small amounts, and chewed thoroughly.
• Instruct patients to manage increased ileostomy output with a soluble fiber supplement (i.e., Metamucil®, psyllium, Konsyl, FiberCon®, Fiber Gummies), which can be slowly increased up to four times daily.
• Teach patients to manage excessive and inappropriate output with antimotility agents (i.e., Imodium®, lomotil, octreotide); these agents should be added one at a time and titrated slowly to avoid paralytic ileus or obstruction.

Colostomy Patients (Landmann, 2020)

• There aren’t any absolute dietary restrictions, and 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 needed, but 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, with the exception of 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, 2020)

Close to 50% of all stomas eventually develop complications due to pouching and peristomal skin issues. Very early complications that occur within days of surgery may be related to technical issues and often require a return to the operating room.

Early Complications
Early complications occur within 3 months of the operative procedure, are often related to poor stoma site selection, and are influenced by age, poor nutritional status, comorbidities, obesity, tobacco use, and underlying malignancy.

• Stomal necrosis
  • Stomal necrosis is characterized by dark brown to black stoma coloration.
  • It may occur following emergency surgery, due to obesity, or inflammatory bowel disease, such as Crohn’s disease.
  • It most commonly occurs in the early postoperative period due to venous congestion or arterial insufficiency.
  • Management includes observation or surgical revision.
• Stomal bleeding
  • Minor bleeding is normal in the immediate postoperative period and may result from “vigorous” stoma cleaning.
  • Major bleeding from the stoma is rare but may be caused by a stomal laceration from a poorly fitted pouch system, or by peristomal varices due to portal hypertension.
  • 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.
  • This may lead to leakage and difficulties with pouch adherence.
  • Risk factors include obesity, thick abdominal wall, foreshortened mesentery, and initial stoma height less than 10 mm.
  • Management
    • Administer local wound care.
    • Use a convex pouching 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
Late complications occur 3 months after surgery. Risk factors include duration of stoma, increases in intra-abdominal pressure (obesity, chronic obstructive pulmonary disease), emergency surgery, height of stoma less than 10 mm, and inappropriately sized aperture.

• Parastomal hernias 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.
  • The highest rates of prolapse occur with loop-transverse colostomies, and end- descending colostomies.
  • Uncomplicated prolapse can be managed with cool compresses and/or osmotic agents (i.e., 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.
  • Stomal stenosis may occur in early postoperative period, but it’s more likely to develop months later.
  • Stomal stenosis may result from peristomal sepsis, retraction, poor fitting pouch system, suboptimal surgical technique, Crohn’s disease, or primary or recurrent malignancy.
  • 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 (i.e., avoid insoluble fiber).
  • Significant stenosis causes cramps and explosive output, and usually requires surgery.

 
Peristomal Skin Problems
Peristomal skin problems are the most common complications that can occur early or late, and they are more prevalent with ileostomies than colostomies. Examples include:

• Mechanical trauma
  • Problems from mechanical trauma often 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
  • Dermatitis can 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.
• Pyoderma gangrenosum (PPG)
  • PPG is an uncommon ulcerative condition seen in patients 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
  • There is no definitive diagnostic test; skin biopsy will show chronic inflammation and will rule out cancer and Crohn’s disease
  • Obtain cultures from the ostomy to assess for infection.
  • Manage with systemic, intralesional, and/or topical anti-inflammatory agents, such as corticosteroids and calcineurin inhibitors.
  • Other treatment options include tumor necrosis factor alpha inhibitors, such as 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, 2020)

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.