What is a stoma and how is it managed?

Understanding Stomas and Their Management

A stoma is a surgically created opening on the abdomen that allows waste (stool or urine) to exit the body when the normal route is unavailable or compromised. 1, 2 Stomas are essential interventions that improve quality of life and reduce mortality in patients with various gastrointestinal or urinary conditions.

Types of Stomas

Colostomy

• Created from a portion of the colon
• Common indications: colorectal cancer, diverticulitis with perforation, trauma, Crohn's disease, fecal diversion needs
• Usually constructed from sigmoid, descending, or transverse colon
• Output is typically formed stool with bowel movements once daily
• Appliances usually changed every 6-7 days 1

Ileostomy

• Constructed from terminal ileum near ileocecal valve
• Common indications: colorectal cancer, inflammatory bowel disease, colonic dysmotility
• Produces liquid effluent requiring emptying 3-4 times daily
• Wafer typically changed every 4 days
• More prone to dehydration and skin excoriation than colostomies 1

Stoma Configurations

End Stoma

• Created when intestine is divided with proximal end brought out as stoma
• Distal end remains in abdomen or occasionally brought out as mucus fistula
• Easiest for patients to manage
• Used for permanent stomas or after intestinal perforation requiring resection 1

Loop Stoma

• Created by bringing continuous intestine through abdominal wall and opening anterior wall
• Results in two openings side by side within same skin aperture
• Proximal end (draining stool) is typically dominant
• Used for distal obstructions or temporary diversion 1

Proper Stoma Management

Pouching System

• Ensure appliance opening is cut one-eighth inch larger than stoma
• Apply techniques to bolster stoma height if needed:
  • Convex appliance
  • Ostomy belt
  • Paste or barrier rings around stoma 2

Preventing and Managing Leakage

• Ensure peristomal skin is completely dry before application
• Heat appliance with hair dryer before application
• Have patient lie flat for several minutes after application
• Apply fine dusting of stomal powder followed by skin sealant 2

Skin Care

• Monitor for dermatological problems:
  • Allergies (presenting as itching and redness in shape of appliance)
  • Fungal infections (itchy maculopapular rash with satellite borders)
  • Folliculitis
• Apply antifungal powder and seal with sealant for fungal infections
• Refer to surgeon or enterostomal therapist if no improvement after 2 weeks 1

Common Complications

Parastomal Hernia

• Occurs in up to 50% of ostomates within 5 years
• Presents as bulge in skin and soft tissue surrounding ostomy
• Manage small, reducible hernias with hernia belt
• Consider surgical evaluation for significant pouching issues, pain, or recurrent obstruction 1, 2

Stomal Prolapse

• Elongation of intestinal portion of stoma (5-10% occurrence rate)
• Acute prolapse can lead to incarceration and ischemia requiring emergency surgery
• Management of non-ischemic prolapse:
  • Place patient in relaxed position
  • Gently squeeze ostomy back into abdomen
  • If needed, apply cup of sugar directly to stoma for 20 minutes 1, 3

High Ostomy Output

• Treatment strategies include:
  • Bulking agents (psyllium fiber, guar gum)
  • Antimotility agents (loperamide, diphenoxylate with atropine)
  • Antisecretory agents (PPIs, octreotide)
  • Anti-inflammatory agents for IBD-related issues 1

Perioperative Considerations

Preoperative Planning

• Preoperative education and stoma site marking significantly improves quality of life and decreases complications 1
• Consult wound ostomy and continence (WOC) services
• Mark site within rectus muscle, away from scars, skin folds, bony prominences, and umbilicus 1, 4

Psychological Support

• Address patient concerns regarding:
  • Fear of leakage and odor
  • Disclosure to partners, family, and friends
  • Clothing considerations
  • Intimacy issues
  • Travel concerns
  • Self-care difficulties 1, 5

When to Seek Professional Help

• Persistent leakage despite interventions
• Signs of stomal ischemia (pain, obstipation, purple/black discoloration)
• Worsening peristomal skin complications
• Painful ulcers with purple halo (possible pyoderma gangrenosum) 1, 2

Clinical Pearls

• Regular measurement of stoma size is essential as dimensions change over time
• Promptly adjust appliance size as needed to prevent leakage and skin complications
• Monitor for body habitus changes that may affect fit
• Multidisciplinary coordination between surgeons, WOC nurses, and gastroenterologists improves outcomes
• Patients with IBD require special attention for potential peristomal pyoderma gangrenosum
• Community-based and online ostomy support groups provide valuable resources for patients 1, 2