What to do if there's blood in colostomy stool?

Blood in Colostomy Stool: Management Approach

Immediately assess hemodynamic stability by checking vital signs and calculating shock index (heart rate/systolic BP), as this determines whether you proceed with urgent resuscitation and surgery versus systematic diagnostic evaluation. 1

Immediate Assessment

• Check vital signs, measure hemoglobin/hematocrit, and assess coagulation parameters to evaluate bleeding severity 2, 1
• Calculate shock index—a value <1 defines hemodynamic stability 1
• For severe bleeding, obtain blood typing and cross-matching immediately 2, 1
• Perform focused history to identify risk factors: portal hypertension, recent endoscopic procedures, inflammatory bowel disease, or known colorectal cancer 2

Management Algorithm Based on Hemodynamic Status

For Hemodynamically Unstable Patients (Shock Index ≥1):

• Begin immediate IV fluid and blood product resuscitation to normalize blood pressure and heart rate 2, 1
• Transfuse packed red blood cells to maintain hemoglobin >7 g/dL (use 9 g/dL threshold if massive bleeding or cardiovascular comorbidities present) 2, 1
• Perform CT angiography as first-line investigation before endoscopy—CTA detects bleeding at rates as low as 0.3 mL/min 1, 3
• Proceed to immediate surgery if patient remains non-responsive to resuscitation 2, 1

For Hemodynamically Stable Patients:

Examine the stoma itself first, then evaluate the excluded bowel distal to the colostomy, as both can be bleeding sources.

Step 1: Evaluate the Stoma

• Inspect the stoma directly for mucocutaneous separation, stomal necrosis, variceal bleeding, or trauma 4
• If portal hypertension is suspected (history of cirrhosis, varices), consider stomal varices as the source—angiography with splenoportography establishes this diagnosis 5
• Stomal variceal bleeding may require portosystemic shunt for definitive control, as local measures are often ineffective 5

Step 2: Evaluate the Excluded Bowel

• Perform endoscopic examination of the colon distal to the colostomy, as 80% of patients have abnormal findings including diversion colitis, polyps, or carcinoma 6
• Sigmoidoscopy or colonoscopy of the excluded segment should be performed to identify diversion colitis, retained stool/mucous plugs, polyps, or malignancy 6
• Upper endoscopy should also be performed to exclude upper GI sources 2

Step 3: Advanced Imaging if Endoscopy Non-diagnostic

• If bleeding source not identified on endoscopy, perform contrast-enhanced CT scan 2
• Consider EUS with color Doppler for deep rectal varices if varices suspected but not visualized 2

Specific Clinical Scenarios

Portal Hypertension with Stomal Varices:

• Temporarily suspend beta-blockers during acute bleeding 2
• Attempt endoscopic variceal ligation, band ligation, sclerotherapy, or EUS-guided glue injection if feasible 2
• For refractory stomal variceal bleeding, portosystemic shunt (such as mesocaval interposition graft) provides definitive control 5
• Involve hepatology team early for multidisciplinary management 2

Diversion Colitis in Excluded Bowel:

• Treat with local steroid enemas or consider colostomy closure as definitive therapy 6
• Removal of excluded colon is rarely necessary even in severe diversion colitis 6

Post-Polypectomy Bleeding:

• If recent polypectomy in excluded bowel, bleeding may occur up to 15 days post-procedure 2
• Endoscopic management options include loop ligation, band ligation, epinephrine injection followed by thermal therapy, or endoclip placement 2

Inflammatory Bowel Disease:

• If patient has known IBD with ≥6 bloody stools daily plus tachycardia >90 bpm, fever >37.8°C, anemia (Hgb <10.5 g/dL), or ESR >30 mm/h, this defines acute severe colitis requiring urgent evaluation 1
• Subtotal colectomy with ileostomy is indicated for life-threatening hemorrhage non-responsive to medical therapy 2, 1

Critical Pitfalls to Avoid

• Do not delay CT angiography in unstable patients—perform before endoscopy 1, 3
• Do not assume the stoma itself is the only potential bleeding source; the excluded bowel distal to colostomy has abnormal findings in 80% of cases 6
• Do not rely solely on local measures for stomal variceal bleeding from portal hypertension, as these are often ineffective and portosystemic shunting may be required 5
• Do not forget that delayed post-polypectomy bleeding can occur up to 15 days after the procedure 2
• Recognize that approximately 20% of patients requiring ≥4 units transfusion have significant mortality risk 1