What are the indications and management of a colostomy?

Colostomy: Indications and Management

Primary Indications for Colostomy

Colostomy is most commonly indicated for colorectal cancer, diverticulitis with perforation, trauma, Crohn's disease, and fecal diversion needs (including fecal incontinence, sacral wounds, or spinal cord injury). 1

Emergency Indications by Location

Left-sided colon emergencies:

• Hartmann's procedure should be the preferred approach for left-sided obstruction or perforation in stable patients 1
• Loop transverse colostomy is reserved for severely unstable patients or unresectable tumors when SEMS (self-expanding metal stents) is not feasible 1
• Simple loop colostomy is associated with longer hospital stays and need for multiple operations without reducing perioperative morbidity 1

Right-sided colon emergencies:

• Right colectomy with terminal ileostomy is the procedure of choice for both obstruction and perforation 1
• The right colon should be avoided for colostomy creation due to its large diameter and liquid effluent, which leads to large stomas prone to leakage 1
• Loop ileostomy can be fashioned for unresectable right-sided colon cancer 1

Specific Clinical Scenarios

Unstable patients (defined by pH <7.2, temperature <35°C, BE <-8, coagulopathy, or sepsis/septic shock):

• Damage control surgery should be initiated rapidly after resuscitation 1
• For left-sided pathology: Hartmann's procedure is first choice; severely unstable patients receive loop transverse colostomy 1
• Stoma creation should be delayed if open abdomen is required 1

Perforation management:

• Priority is controlling the septic source with prompt combined medical treatment 1
• Oncologic resection should be performed for better outcomes 1
• For perforation at tumor site: formal resection with or without anastomosis, with or without stoma 1
• For diastatic perforation (proximal to tumor): simultaneous tumor resection and management of proximal perforation; subtotal colectomy may be required depending on colonic wall conditions 1

Fournier's gangrene:

• Colostomy is indicated when there is anal sphincter involvement, fecal incontinence, or continued fecal contamination of the wound 1
• Decision should be postponed for at least 48 hours from initial surgery to allow inflammation regression and proper evaluation of sphincters 1

Types of Colostomy

End colostomy:

• Created when intestine is divided with proximal end brought out as stoma 1
• Easiest for patients to pouch 1
• Used most often for permanent stomas or intestinal perforation requiring resection 1

Loop colostomy:

• Created by bringing continuous intestine through abdominal wall and opening anterior wall, resulting in two openings side by side 1
• Typically constructed from sigmoid, descending, or transverse colon 1

Ongoing Management

Normal Output Expectations

• Colostomy output is typically formed stool occurring once daily, making it significantly easier to manage than ileostomy 1, 2
• Appliances usually require changing once every 6-7 days 1, 2, 3

Monitoring Requirements

• Regular assessment of stoma output volume is essential for early detection of abnormalities 2, 3
• High ostomy output (HOO) is defined as output >1.5 L/day 2
• When output exceeds 2000 mL/24h, patients are at high risk for dehydration, electrolyte depletion (particularly sodium and magnesium), and malnutrition 2

Laboratory Monitoring

• Serum electrolytes (sodium, potassium, magnesium) should be monitored 2
• Random urinary sodium <20 mmol/L suggests sodium depletion 2

Management of High Output

• Restrict hypotonic/hypertonic fluids to <1000 mL daily 2, 3
• Medications include bulking agents (psyllium fiber, guar gum), antimotility agents (loperamide, diphenoxylate/atropine, codeine, tincture of opium), and antisecretory agents (proton pump inhibitors, H2 antagonists, somatostatin analogues) 2
• Proper hydration and electrolyte balance are crucial to prevent renal failure 2, 3

Skin Care and Complications

• Evaluate peristomal skin for fungal infections or pyoderma gangrenosum 3
• For peristomal skin irritation, recommend appropriate barrier products and refer to wound ostomy continence (WOC) specialists if no improvement within 2 weeks 3
• For stomal prolapse without ischemia, patients can be instructed on gentle reduction techniques 3
• Emergency surgical referral is needed for painful, obstructed, or discolored (purple/black) stomas 3

Coordination of Care

• Establish communication with enterostomal therapists or IBD specialist nurses for optimal interdisciplinary management 3
• Studies demonstrate that adequate stomal care improves clinical outcomes and reduces hospitalizations 1, 3
• 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 3

Common Pitfalls to Avoid

• Do not perform simple loop colostomy for left-sided obstruction in stable patients—Hartmann's procedure is superior 1
• Avoid creating colostomy from right colon due to liquid effluent and leakage risk 1
• Do not delay surgical intervention in Fournier's gangrene—early aggressive debridement improves survival 1
• Only a small proportion of patients undergo reversal of terminal stoma, so consider this when planning initial surgery 1