Management of Bowel Movements from a Hartmann Pouch
After a Hartmann procedure, patients do not have bowel movements from the rectal pouch because it is a defunctionalized blind segment with no intestinal continuity—all stool is diverted through the end colostomy. 1
Understanding the Hartmann Anatomy
- The Hartmann procedure creates a complete separation of the bowel, with an end colostomy for stool diversion and a closed rectal stump (the "Hartmann pouch") that remains in the pelvis 2, 1
- This rectal pouch is defunctionalized, meaning no fecal stream passes through it, and therefore patients have zero bowel movements from this segment 3
- All bowel movements occur exclusively through the abdominal colostomy 1
What Patients Experience from the Rectal Pouch
- Mucus discharge: The rectal pouch continues to produce mucus, which patients may pass rectally—this is normal and not a bowel movement 3
- The amount of mucus varies but is typically minimal and does not represent fecal material 3
- Some patients may experience a sensation of rectal fullness or pressure from mucus accumulation 3
Potential Complications of the Defunctionalized Pouch
Diversion colitis develops in virtually every Hartmann pouch examined endoscopically, though it is usually mild and asymptomatic 3:
- Mild inflammation occurs in nearly 100% of pouches due to lack of fecal stream and short-chain fatty acid deficiency 3
- Severe colitis requiring pouch removal occurred in 11 patients with inflammatory bowel disease, 3 with diverticulitis, and 1 with cancer in one series 3
Long-term monitoring concerns for patients with permanent Hartmann pouches 4, 5:
- Neoplasm formation can occur in long-term defunctionalized pouches, warranting close observation with proctoscopy and contrast studies 4
- Other pathologic lesions include ulcers, bleeding, strictures, and recurrent disease 4, 5
- Contrast-enhanced radiography detected abnormalities in 19% of patients, including leaks, fistulas, adhesions, and recurrent tumors 5
Restoration of Bowel Continuity
- Approximately 57% of surviving patients eventually undergo reversal surgery to restore intestinal continuity and eliminate the colostomy 6
- The average time between initial resection and reanastomosis is 149 days (approximately 5 months) 6
- Many patients never undergo reversal and remain with a permanent colostomy and defunctionalized rectal pouch 2, 1
Critical Pitfall to Avoid
- Do not confuse mucus discharge with bowel movements—patients and providers must understand that the rectal pouch produces only mucus, not stool, and this is expected 3
- If a patient reports actual fecal material passing rectally after a Hartmann procedure, this indicates a fistula between the colostomy and rectal pouch and requires immediate surgical evaluation 5