What is the role of a primary care physician (PCP) in managing a patient with a colostomy?

Primary Care Physician's Role in Colostomy Management

Primary care physicians play a crucial role in managing patients with colostomies through regular assessment, complication monitoring, and coordination with specialists to improve quality of life and reduce hospitalizations. 1

Understanding Ostomy Types and Basic Care

• Colostomies are the most common type of enteral stoma, typically created from the sigmoid, descending, or transverse colon for conditions including colorectal cancer, diverticulitis with perforation, trauma, Crohn's disease, and fecal diversion 1
• Colostomy output is typically formed stool occurring once daily, making it easier to manage than ileostomy output, with appliances usually requiring changes every 6-7 days 1, 2
• Ileostomies produce liquid effluent requiring emptying 3-4 times daily with normal output less than 1.5 L/day, and are associated with higher risk of dehydration and skin excoriation 1, 2

PCP's Monitoring Responsibilities

• Regular assessment of stoma output volume is essential for early detection of abnormalities, particularly monitoring for high output (>1.5 L/day) which can lead to dehydration and electrolyte imbalances 2
• Laboratory monitoring should include serum electrolytes (sodium, potassium, magnesium), with random urinary sodium <20 mmol/L suggesting sodium depletion 2
• PCPs should assess for common complications including skin excoriation, chronic blood loss, and stoma prolapse during regular follow-up visits 3
• Evaluation of peristomal skin for fungal infections (presenting as itchy maculopapular rash with satellite borders) or pyoderma gangrenosum (painful ulcers surrounded by purple halo, particularly in IBD patients) 1

Complication Management

• For peristomal skin irritation, PCPs should recommend appropriate barrier products and refer to wound ostomy and continence (WOC) specialists if no improvement occurs within 2 weeks 1
• For high ostomy output, PCPs should initiate fluid and electrolyte management, including restriction of hypotonic/hypertonic fluids to <1000 mL daily 2
• Medication management for high output may include bulking agents, antimotility agents, and antisecretory agents 2
• For stomal prolapse without ischemia, PCPs can instruct patients on gentle reduction techniques; however, emergency surgical referral is needed for painful, obstructed, or discolored (purple/black) stomas 1

Coordination of Care

• PCPs should establish communication with enterostomal therapists or IBD specialist nurses for optimal interdisciplinary management, particularly when nutritional concerns arise 1
• Studies show that adequate stomal care improves clinical outcomes and reduces hospitalizations, highlighting the importance of PCP involvement in ongoing care 1
• PCPs should connect patients with community-based and online ostomy support groups to address psychological impacts including fear of leakage, odor, disclosure concerns, clothing issues, intimacy, and travel 1, 4
• Home visits by enterostomal therapists as part of a comprehensive care pathway have been shown to improve quality of life in ostomy patients 4

Nutritional and Lifestyle Guidance

• PCPs should provide nutritional counseling to prevent dehydration, particularly for patients with high-output stomas 1, 2
• Proper hydration and electrolyte balance guidance is crucial to prevent renal failure in patients with high-output stomas 2
• PCPs should address lifestyle modifications and provide educational support when patients don't have access to specialized ostomy care nurses 5
• Regular assessment of nutritional status is particularly important for patients with risk factors such as active disease, having an ileostomy, or remnant small bowel length ≤230 cm 1

When to Refer to Specialists

• Referral to surgeons or enterostomal therapists is indicated for peristomal skin complications not improving after 2 weeks of treatment 1
• Emergency surgical referral is required for acute stoma prolapse with signs of incarceration and ischemia (pain, obstipation, purple/black discoloration) 1
• Consultation with WOC specialists should be considered for ongoing pouching difficulties, persistent skin issues, or significant changes in stoma appearance or function 1
• Multidisciplinary coordination between PCPs, surgeons, and enterostomal therapists is essential to prevent hospital readmissions and improve quality of life 1