How to manage bleeding from a stoma site or newly created mucous fistula?

Assessment and Management of Bleeding from a Stoma Site or Mucous Fistula

When assessing bleeding from a stoma site or surrounding a newly created mucous fistula, daily inspection of the wound area for signs of bleeding, erythema, secretion, and induration is essential, with appropriate cleansing, disinfection, and application of sterile dressings to manage bleeding and prevent infection.

Initial Assessment of Stoma/Fistula Bleeding

Physical Examination

• Carefully inspect the stoma site or mucous fistula for:
  • Amount and character of bleeding (oozing vs. active bleeding)
  • Presence of erythema (note: less than 5mm of reddening around the outer stoma canal is common and often movement-induced, not necessarily infection) 1
  • Secretion, induration, or allergic skin reactions
  • Signs of local infection which may contribute to bleeding
  • Tissue granulation around the stoma site

Common Causes of Bleeding

• Peptic ulcer disease
• Traumatic erosion of the gastric wall opposite the internal bolster
• Ulceration beneath the internal bolster (reported in 0.3%-1.2% of gastrostomy cases) 1
• Excessive lateral traction on the tube
• Excessive tension between internal and external bolsters
• Local wound infection (occurs in approximately 15% of cases) 1
• Stomal varices (in patients with portal hypertension) 2

Management Protocol for Stoma/Fistula Bleeding

Immediate Management

1. For minor bleeding:

   • Apply gentle pressure with sterile gauze
   • Do not apply pressure until any needle/device has been completely removed 1
   • Use Y-compress dressings to avoid formation of moist cavities under external fixation plates 1

2. For more significant bleeding:

   • Apply sterile Y-dressing to compress the area (using material that does not shed fibers) 1
   • Follow with a skin-friendly and solvent-free breathable dressing 1
   • Avoid occlusive dressings as they promote moist wound environments and can lead to skin maceration 1

Wound Care Protocol

1. First dressing change should be performed the morning after stoma/fistula placement 1

2. Until granulation of the stoma canal occurs (usually days 1-7):

   • Change sterile dressing daily
   • Provide local disinfection at each change 1
   • Clean the wound area thoroughly
   • Inspect for bleeding, erythema, secretion, and induration 1

3. Dressing change procedure:

   • Remove dressings and open any fixation plate
   • Dispose of gloves, disinfect hands, and apply new gloves
   • Clean, disinfect, and completely dry the wound area 1
   • Apply a Y-compress under the tube/stoma
   • Secure external fixation with at least 5mm of free movement 1
   • Apply sterile dressing

4. For persistent bleeding:

   • Consider glycerin hydrogel or glycogel dressing as an alternative to classical aseptic wound care during the first weeks 1
   • These have shown statistically significant reduction in infection scores and may help manage bleeding by providing a moist healing environment 1

Special Considerations

For Gastrostomy/PEG Sites

• Ensure the external fixation plate retains the tube without exerting tension on the stoma canal 1
• Allow free movement of the tube of at least 5mm to prevent local ischemia 1
• After initial wound healing (1-2 weeks), cleansing and dressing can be reduced to every 2-3 days 1
• Avoid excessive compression between internal and external fixation devices 1

For Enteroatmospheric Fistulas

• Consider negative pressure wound therapy (NPWT) to manage output and prevent spread of intra-abdominal sepsis 1
• For visible fistulae, consider isolating the fistula with an ostomy bag (floating stoma technique) 1
• NPWT can help achieve secure bag adhesion and manage adjacent wound 1
• In cases with significant granulation tissue, consider application of dermal matrix wound dressing to promote tissue granulation around the fistula 3

Prevention of Complications

• Ensure incision at puncture site is sufficiently large (8mm for gastrostomy) to prevent pressure-related lesions 1
• Use Y-compress to avoid formation of moist cavity under external fixation plate 1
• Ensure external fixation plate retains tube without exerting tension on stoma canal 1
• For gastrostomy tubes, push tube approximately 2-3cm ventrally and carefully pull back to resistance of internal fixation flange during dressing changes to prevent adhesions 1
• After feed or medication administration through tubes, flush with approximately 40ml of drinking water 1

When to Seek Advanced Intervention

• For persistent bleeding despite conservative measures
• For signs of significant infection (increasing erythema, purulence, fever)
• For stomal varices with significant bleeding, consider percutaneous embolization techniques 2
• For bleeding associated with buried bumper syndrome, endoscopic removal and replacement may be necessary 1

By following this systematic approach to assessment and management of bleeding from stoma sites or mucous fistulas, complications can be minimized and proper healing promoted.