What does it mean when a stoma (surgically created opening) in a colostomy is protruding?

Understanding a Protruding Stoma in Colostomy

A protruding stoma in colostomy refers to stomal prolapse, which is the elongation of the intestinal portion of the stoma beyond the abdominal wall, occurring in 5-10% of patients with ostomies. 1 This condition requires careful assessment to distinguish it from other complications and determine appropriate management.

What Stomal Prolapse Is

Stomal prolapse is distinctly different from a parastomal hernia:

• Stomal prolapse: Elongation of the intestinal portion of the stoma itself
• Parastomal hernia: Bulge in the skin and soft tissue surrounding the ostomy

Key Characteristics of Stomal Prolapse:

• Appears as intestinal tissue protruding from the stoma opening
• Can extend several centimeters beyond the abdominal wall
• May be accompanied by redness, swelling, and erosion of the tissue
• More common in loop stomas than end stomas
• Occurs in 5-10% of patients with ostomies 1

Causes and Risk Factors

Several factors contribute to stomal prolapse:

• Increased intra-abdominal pressure
• Redundant or mobile colon
• Emergency stoma creation
• Loop configuration (higher risk than end stomas)
• Transverse colostomy location (particularly high risk)
• Excessive fascia incision during creation
• Inadequate fixation of the stoma to the abdominal wall 2

Clinical Significance and Complications

While stomal prolapse is not immediately life-threatening, it can lead to serious complications:

• Acute complications:

  • Incarceration and ischemia (surgical emergency)
  • Pain, obstipation, and purple/black discoloration of the stoma 1

• Chronic issues:

  • Difficulty with stoma care and appliance fitting
  • Peristomal skin irritation and breakdown
  • Leakage around appliance
  • Psychological distress
  • Impaired quality of life

Management Approaches

Non-surgical Management:

1. Manual reduction:

   • Place patient in a relaxed position
   • Gently squeeze the prolapsed stoma back into the abdomen
   • If unsuccessful with pressure alone, apply a cup of sugar directly to the stoma and leave for 20 minutes to help reduce edema 1

2. Stoma care adaptations:

   • Modify pouching system to accommodate the prolapsed stoma
   • Use larger pouches or custom-cut barriers
   • More frequent appliance changes
   • Consultation with wound/ostomy nurse for specialized care 3

Surgical Management:

Surgical intervention is indicated when:

• Conservative management fails
• Complications make traditional care difficult
• Normal bowel function is affected
• Incarceration or ischemia occurs 2

Surgical options include:

1. Stoma reversal (if medically appropriate)
2. Repair techniques:
   • Fixation of the intestine to prevent prolapse
   • Shortening of the redundant intestine
   • Elimination of space between stoma and abdominal wall 2
   • Stapling techniques for tissue reduction 4

Prevention Strategies

To minimize risk of stomal prolapse:

• Preoperative stoma site marking by a wound/ostomy specialist
• Appropriate selection of intestinal segment
• Avoiding excessive fascia incision
• Proper fixation of the stoma to the abdominal wall
• Using extraperitoneal route when possible
• Placing stoma through rectus muscle
• Avoiding transverse colon for stoma creation when possible 1, 2

When to Seek Immediate Medical Attention

Patients should seek emergency care if the prolapsed stoma:

• Cannot be reduced
• Becomes painful
• Changes color (especially purple or black)
• Stops producing output
• Shows signs of obstruction (abdominal pain, distention, nausea/vomiting)

These symptoms may indicate incarceration and ischemia, which is a surgical emergency requiring immediate intervention 1.