Management of Colostomy Diarrhea with Peristomal Leakage
For a patient with a colostomy experiencing diarrhea and leakage around the stoma, immediately address the diarrhea with loperamide to reduce output volume while simultaneously optimizing the pouching system with convex appliances and barrier products to prevent skin breakdown. 1, 2
Immediate Pharmacologic Management
Reduce Stoma Output
- Loperamide is FDA-approved specifically for reducing discharge volume from ostomies and controlling diarrhea, making it the first-line pharmacologic intervention 1
- Antimotility agents like loperamide can reduce colostomy output by 13-75%, with mean reductions of approximately 45% 3
- Consider bulking agents and antisecretory medications as adjunctive therapy if loperamide alone is insufficient 4
Fluid and Dietary Modifications
- Restrict hypotonic and hypertonic fluids to less than 1000 mL daily to help reduce output 4
- Assess for triggers causing increased output, including dietary indiscretions, infections, or medication side effects 5
Concurrent Pouching System Optimization
Appliance Selection and Application
- Switch to convex appliances immediately, as these create outward pressure that improves the seal between appliance and peristomal skin, preventing leakage 2
- Apply an ostomy belt in conjunction with the convex appliance to maintain consistent pressure 2
- Cut the appliance opening one-eighth inch larger than the stoma to prevent mucosal irritation while minimizing skin exposure to liquid effluent 2
Barrier Products
- Use paste or barrier rings around the stoma base to fill gaps and create a level surface for appliance adhesion 2
- Apply stomal powder followed by skin sealant on any damaged peristomal skin before placing the appliance 2
- Ensure the peristomal skin is completely dry before applying any pouching system, as moisture compromises adhesion 2
Application Technique
- Heat the appliance with a hair dryer before application to improve adhesion 2
- Lie flat for several minutes after application to enhance seal formation 2
Monitoring and Assessment
Output Monitoring
- Measure and document 24-hour stoma output volume, as normal colostomy output should be formed stool occurring once daily 4
- High output (>1.5 L/day or greater than fluid intake) indicates inadequate control and requires escalation of therapy 4
Skin Assessment
- Monitor closely for peristomal skin breakdown from leakage, as this is a secondary complication requiring immediate intervention 2
- Ileostomy patients experience more leakage and peristomal complications than colostomy patients, though both require vigilant monitoring 6
Appliance Change Frequency
- During acute diarrhea episodes, appliance changes may need to occur more frequently than the typical 6-7 day interval for colostomies 5
- Measure stoma size at each change if within the first 8 weeks post-surgery, as the stoma continues to evolve during this period 2
Common Pitfalls to Avoid
- Do not ignore persistent leakage, as it causes significant financial burden from frequent appliance changes and progressive skin damage that may eventually require surgical intervention 2
- Avoid placing the appliance on moist skin, as this is a primary cause of seal failure 2
- Do not assume all leakage is due to appliance issues—always address the underlying cause of increased output first 4
When to Refer
Wound Ostomy Continence (WOC) Nurse Consultation
- Refer to a WOC specialist if leakage persists despite initial interventions, as specialized expertise significantly reduces complications 2, 7
- WOC nurses provide crucial support for appliance selection and application techniques that general nurses may not possess 6