How to manage stomal prolapse with decreased output?

Management of Stomal Prolapse with Decreased Output

In cases of stomal prolapse with decreased output, immediate assessment for stoma viability is essential, followed by gentle manual reduction if no ischemia is present, and emergency surgical intervention if ischemia is evident. 1

Initial Assessment and Management

Evaluate for Stoma Viability

• Check for signs of ischemia (pain, obstipation, purple/black discoloration of the stoma) 1
• Assess for complete obstruction causing decreased output
• Determine if the prolapse is reducible

Management Algorithm Based on Stoma Condition

If No Ischemia Present:

1. Attempt gentle reduction:
   • Place patient in a relaxed position
   • Gently squeeze the ostomy back into the abdomen 1
   • If initial attempts fail, apply a cup of sugar directly to the stoma and leave for 20 minutes before attempting reduction again 1

If Ischemia Present:

• Emergency surgical intervention is required to prevent bowel necrosis and potential sepsis 1

Management of Decreased Output

After addressing the prolapse, focus on managing the decreased output:

Fluid and Electrolyte Management

• Target ileostomy output of 500-700 mL per day 2
• Provide glucose-saline solution with sodium concentration ≥90 mmol/L (1-2L daily) 2
• Monitor hydration status targeting urine output ≥800ml/day with sodium >20 mmol/L 1, 2

Pharmacological Management

1. First-line medications:

   • Loperamide 2-8 mg before meals (can be increased to 12-24 mg for severe cases) 1, 2
   • If tablets emerge unchanged in stomal output, crush them and mix with water or food 1

2. Second-line options if needed:

   • Add codeine phosphate (30-60mg four times daily) if loperamide alone is insufficient 1, 2
   • Consider antisecretory drugs for high-volume output:
     • Omeprazole 40 mg once daily
     • Ranitidine 300 mg twice daily
     • Cimetidine 400 mg four times daily 1

Dietary Modifications

• Consume foods that thicken output: bananas, pasta, rice, white bread, mashed potato 2
• Add 0.5-1 teaspoon of salt to meals daily 2
• Consider small, frequent, nutrient-dense meals 2
• Restrict oral hypotonic fluids to <500 mL daily 1, 2

Surgical Options for Persistent Prolapse

If conservative management fails and the prolapse persists with decreased output:

• Surgical repair should be considered when complications make traditional care difficult and/or when the prolapse affects normal bowel function 3
• Surgical repair methods include:
  1. Methods to fix the intestine to prevent mobility
  2. Methods to shorten the intestine
  3. Methods to eliminate the space between the stoma and the abdominal wall 3
• For high-risk patients, local repair with a stapler device may be considered as a minimally invasive option 4

Monitoring and Follow-up

• Regular monitoring of electrolytes (sodium, potassium, magnesium)
• Assess for dehydration and renal function
• Monitor vitamin B12, zinc, and selenium levels 2
• Evaluate for potential causes of decreased output:
  • Partial obstruction
  • Intra-abdominal sepsis
  • Enteritis
  • Recurrent disease in remaining bowel 1

Pitfalls to Avoid

• Do not encourage excessive oral hypotonic fluid intake, which can worsen sodium losses 1
• Do not delay surgical intervention if signs of ischemia are present 1
• Do not overlook the need to correct hypomagnesemia, which can lead to resistant hypokalemia 1, 2
• Do not miss underlying causes of decreased output such as partial obstruction or infection 1

By following this algorithm, the management of stomal prolapse with decreased output can be optimized to prevent serious complications and improve patient outcomes.