Is it normal for a patient to have large amounts of stool coming from the rectum 5 days after a diverting loop sigmoid colostomy?

Rectal Stool Output After Diverting Loop Sigmoid Colostomy: Urgent Evaluation Required

This patient needs immediate surgical evaluation and likely return to the hospital, as large amounts of stool from the rectum 5 days post-colostomy indicates failure of fecal diversion, which is abnormal and potentially dangerous.

Understanding Normal Loop Colostomy Function

A properly functioning diverting loop sigmoid colostomy should achieve complete fecal diversion 1, 2. The anatomy consists of:

• Proximal limb (dominant): Should drain all stool into the ostomy bag 1, 2
• Distal limb (diminutive): The defunctionalized segment including the rectum 1, 2

What Should Come From the Rectum Normally

The only expected discharge from the rectum after a diverting colostomy is:

• Mucus production: The defunctionalized distal segment continues to produce mucus from the intestinal lining, which is normal and expected 1, 2
• Small amounts of mucus discharge: This is physiologic and does not represent stool 1, 2

Why Large Stool Output Is Abnormal

Large amounts of stool passing through the rectum indicates the colostomy is not adequately diverting fecal stream 2. This represents:

• Failure of diversion: The proximal limb is not adequately dominant, allowing stool to pass through the distal segment 2
• Potential surgical complication: This may indicate technical issues with the colostomy construction 1

Specific Concerns in This Patient

Given this patient's complex medical history, failure of diversion is particularly concerning:

• Recent pulmonary embolism on anticoagulation: Risk of bleeding complications [@question context@]
• Multiple comorbidities (cirrhosis, CHF, COPD, afib): Poor physiologic reserve [@question context@]
• Original indication was colonic obstruction: Stool passing distally suggests the obstruction is not adequately bypassed [@question context@]
• Only 5 days post-operative: Early postoperative period when complications are most likely 1

Immediate Management Algorithm

Step 1: Contact the surgeon immediately - This requires urgent surgical consultation 1

Step 2: Assess for complications:

• Signs of obstruction (abdominal distention, pain, nausea/vomiting) 1
• Signs of perforation or peritonitis (fever, hemodynamic instability, peritoneal signs) 1
• Adequacy of ostomy output from the colostomy itself 1

Step 3: Arrange transfer back to hospital for:

• Physical examination by the surgical team 1
• Possible imaging (CT abdomen/pelvis with contrast) to evaluate colostomy function and rule out complications 1
• Potential revision surgery if diversion failure is confirmed 1

Common Pitfalls to Avoid

• Assuming this is normal: Unlike mucus discharge, large amounts of stool are never normal from a defunctionalized rectum 2
• Delaying surgical consultation: Early recognition and intervention prevent progression to complete obstruction or perforation 1
• Attributing symptoms to other causes: In the early postoperative period, new symptoms should be considered surgical complications until proven otherwise 1

Why This Cannot Wait

The original surgery was performed for colonic obstruction [@question context@]. If stool is passing through the rectum in large amounts:

• The obstruction may not be adequately bypassed 1
• The colostomy may be malfunctioning 1, 2
• Risk of complete obstruction, ischemia, or perforation at the original obstruction site 1
• In a patient with cirrhosis and multiple comorbidities, delayed recognition could be catastrophic 1

Bottom line: This is not normal postoperative function and requires same-day surgical evaluation, likely necessitating hospital transfer.