How to manage a patient with colostomy leakage and abdominal discomfort?

Management of Colostomy Leakage and Abdominal Discomfort

For a patient experiencing colostomy leakage and abdominal discomfort, immediate management should focus on addressing the leakage through proper pouching techniques, thickening stool consistency, and evaluating for potential complications such as parastomal hernia or skin irritation. 1

Initial Assessment

• Evaluate the stoma for:

  • Size (measure at each appliance change)
  • Position (check if flush with skin or within skin creases)
  • Presence of parastomal hernia (bulging around stoma)
  • Signs of stomal prolapse (elongation of intestinal portion)
  • Peristomal skin condition (irritation, excoriation, fungal infection)

• Assess the current pouching system:

  • Proper fit (should be one-eighth inch larger than stoma)
  • Integrity of seal
  • Appropriate type for stoma configuration

Management of Colostomy Leakage

Immediate Interventions

1. Pouching Technique Optimization:

   • Ensure the appliance opening is cut one-eighth inch larger than the stoma to minimize skin exposure while preventing mucosal irritation 1
   • Apply techniques to bolster stoma height:
     • Use convex appliance
     • Add ostomy belt
     • Apply paste or barrier rings around stoma 1

2. Application Techniques:

   • Ensure peristomal skin is completely dry before application
   • Heat the appliance with a hair dryer before application
   • Have patient lie flat for several minutes after application
   • Apply fine dusting of stomal powder followed by skin sealant on peristomal skin 1

3. Stool Consistency Management:

   • Administer antidiarrheals to thicken stool and create more solid effluent 1
   • Consider dietary modifications to reduce liquid output

Addressing Peristomal Skin Issues

1. For skin irritation from leakage:

   • Apply zinc oxide or stoma adhesive powder to protect skin 2
   • Use foam dressings rather than gauze (foam lifts drainage away from skin) 1, 2
   • Apply skin sealant to minimize irritation 1

2. For fungal infections:

   • Apply antifungal powder to affected areas
   • Seal with skin sealant
   • If no improvement after 2 weeks, refer to surgeon or enterostomal therapist 1

Evaluation for Underlying Causes

Parastomal Hernia Assessment

• Parastomal hernias occur in up to 50% of ostomates within 5 years 1
• If small and reducible, manage with hernia belt
• If causing significant pouching issues, pain, or recurrent obstruction, consider surgical evaluation 1

Stomal Prolapse Evaluation

• Check for elongation of intestinal portion of stoma (occurs in 5-10% of cases)
• If not ischemic, may be reduced by:
  • Placing patient in relaxed position
  • Gently squeezing ostomy back into abdomen
  • If needed, applying sugar directly to stoma for 20 minutes 1

When to Seek Specialist Consultation

• Refer to wound ostomy and continence (WOC) nurse or surgeon if:
  • Leakage persists despite interventions
  • Signs of stomal ischemia (pain, obstipation, purple/black discoloration)
  • Peristomal skin complications worsen or don't improve
  • Painful ulcers with purple halo (possible pyoderma gangrenosum) 1

Prevention of Future Leakage

• Regular measurement of stoma size (especially during first 8 weeks)
• Prompt adjustment of appliance size as needed
• Monitoring for body habitus changes that may affect fit
• Proper education on ostomy care and management 1

Common Pitfalls to Avoid

• Cutting appliance opening too large or too small
• Applying excessive pressure between external and internal bolsters
• Neglecting early signs of skin irritation or infection
• Failing to address underlying causes of leakage
• Inadequate patient education on ostomy management 1

By following this structured approach to managing colostomy leakage and associated abdominal discomfort, you can effectively address both the immediate symptoms and potential underlying causes, improving patient comfort and preventing complications.