What is the best course of action for a patient with a constantly leaking ileostomy (intestinal stoma) every 1-2 hours, increased output, and cellulitis (bacterial skin infection) at the site?

From the Guidelines

The patient with a constantly leaking ileostomy, increased output, and cellulitis at the site requires immediate medical attention, and the best course of action is to address the cellulitis, increased output, and leaking stoma simultaneously. The patient should contact their healthcare provider or go to the emergency department, as this combination of symptoms indicates a serious complication requiring professional assessment. Treatment typically involves addressing three key issues simultaneously:

• The cellulitis should be treated with antibiotics, commonly dicloxacillin 500mg four times daily or cephalexin 500mg four times daily for 7-10 days (or intravenous antibiotics if severe) 1.
• The increased output should be managed with anti-diarrheal medications such as loperamide 2-4mg three to four times daily (maximum 16mg/day) or diphenoxylate/atropine 2.5-5mg four times daily, along with oral rehydration solutions to prevent dehydration 1.
• The leaking stoma requires proper appliance fitting by a wound/ostomy nurse, possibly using a convex appliance, barrier rings, or stoma paste to create a better seal, as suggested by the most recent guidelines on ostomy management 1. The patient should also modify their diet by reducing high-output foods (spicy foods, caffeine, alcohol), increasing soluble fiber, and ensuring adequate hydration with electrolyte-rich fluids, as recommended by the British Society of Gastroenterology consensus guidelines on the management of inflammatory bowel disease in adults 1. These interventions are crucial because untreated cellulitis can progress to serious infection, while ongoing leakage and high output can lead to severe skin breakdown, electrolyte imbalances, and dehydration requiring hospitalization. Given the patient's situation, ordering an ostomy provider consult is a necessary step to ensure proper management of the leaking ileostomy and to prevent further complications. Some key considerations for the patient's diet include:
• Avoiding chronic dehydration and advising 2–2.5 litres of fluids per day, more during hot weather or exercise 1.
• Increasing intake of potassium-rich foods, such as bananas, potatoes, and spinach, if serum potassium is low 1.
• Avoiding high intakes of hypotonic and hypertonic drinks, and encouraging isotonic drinks instead 1.
• Recommending 1–2 tablets (2–4 mg) loperamide half hour before meals to help thicken output 1.

From the Research

Patient Condition

The patient has a constantly leaking ileostomy every 1-2 hours, increased output, and cellulitis at the site. This condition is causing the patient's skin to become raw and painful.

Possible Complications

• Peristomal dermatitis caused by watery and highly alkaline effluent 2
• Skin infections, such as cellulitis, which can be treated with antibiotics and proper wound care 2, 3
• High output stoma (HOS), defined as output exceeding 1,000-2,000 ml/day, which can be treated with intravenous fluid and electrolyte resuscitation, restriction of hypotonic fluid, and antimotility drugs 2

Management Options

• Ostomy provider consult to assess and manage the patient's ileostomy and peristomal skin 2, 3
• Use of skin protective products, such as barrier creams, gels, lotions, sprays, and wipes, to prevent damage to the peristomal skin 4, 5
• Convex stoma appliances to protect the skin against fecal leakage 2
• Re-education on stoma care technique and use of stoma accessories, such as skin protectors, paste, or seals, to reduce effluent leakage and prevent damage to the peristomal skin 3, 5

Multidisciplinary Approach

• Collaboration with a multidisciplinary team, including ostomy nurses, dermatologists, and wound care specialists, to manage the patient's peristomal skin complications and prevent further damage 3, 5