What is the best approach to managing a patient with a stoma?

Optimal Management of Patients with a Stoma

Stoma management requires early involvement of specialized stoma nurses and an interdisciplinary team approach, with particular attention to preventing high-output complications through fluid restriction, pharmacologic interventions, and proper appliance fitting. 1

Core Management Principles

Early Specialist Involvement

Stoma therapists or IBD specialist nurses must be involved as early as possible whenever a patient receives an enterostomy. 1 This is critical because:

• Preoperative stoma site marking by wound ostomy and continence (WOC) nurses decreases peristomal skin complications and improves quality of life 2, 3, 4
• Preoperative marking reduces total complications from 43.5% to 32.5% (p<0.0075) and early complications from 31.6% to 23.3% (p<0.03) 4
• Placement through the rectus muscle rather than lateral to it reduces retraction risk 3
• Emergency stoma patients often miss preoperative marking, which is a risk factor for problematic stomas 1

Interdisciplinary Team Structure

When an enterostomy becomes a cause of concern, management is best addressed by an interdisciplinary team, particularly when nutritional concerns arise. 1

The team should include 1:

• Nurses (key members who require robust education programs on ERAS principles) 1
• Stoma specialist nurses (often weekday-only service, creating weekend care gaps) 1
• Physiotherapy (for mobilization goals) 1
• Nutritionists (for high-output management) 1
• Consider an emergency laparotomy program coordinator for continuity through care transitions 1

High-Output Stoma Management

Definition and Risk Assessment

High-output stoma (HOS) is defined as 1:

• 1000-2000 mL/24h effluent 1
• When output exceeds 2000 mL/24h, dehydration, sodium/magnesium depletion, and malnutrition occur 1
• Most common in jejunostomy patients, unlikely in colostomy with retained small bowel 1
• Common within 3 weeks of surgery; spontaneous resolution occurs in half of patients 1
• Dehydration requiring hospital admission occurs in up to 17% of patients after colorectal resection with diverting loop ileostomy 1

Mandatory Assessments

Nutritional and clinical assessments must be performed on all patients with high-output stoma. 1

Laboratory investigations include 1:

• Serum urea and creatinine
• Sodium, potassium, magnesium
• Urinary sodium (random urinary sodium <20 mmol/L suggests sodium depletion)
• Vitamin B12 and iron (provide replacement if deficient)
• Consider selenium, zinc, and vitamins A, D, E, K assessment

Fluid Management Protocol

HOS patients should restrict hypotonic/hypertonic fluids to <1000 mL daily, with remaining fluid requirements met by oral intake of isotonic glucose-saline solution. 1

This is critical because 1:

• Large volume of gastric secretion minimizes absorption time
• Electrolyte deficiencies result from both reduced absorption and increased renal excretion
• Replace electrolytes orally or by IV supplementation if oral insufficient

Pharmacologic Interventions

Drug therapy can help reduce intestinal motility or secretions and thereby support absorption. 1

First-line agents include 1, 5:

• Loperamide (first-line, reduces colostomy output by approximately 45%) 5
• Proton-pump inhibitors 1
• Opium 1
• Psyllium fibers (bulk-forming agents may slow gastric emptying and improve stool consistency) 1
• Cholestyramine 1
• Oral budesonide (improves water absorption and decreases stoma output in CD patients with ileostomy) 1

Appliance Management

Proper Fitting Technique

Switch to convex appliances immediately to improve the seal between appliance and peristomal skin, preventing leakage. 5, 3

Key technical points 5, 3:

• Apply an ostomy belt in conjunction with convex appliance to maintain consistent pressure 5, 3
• Cut the appliance opening one-eighth inch larger than the stoma to prevent mucosal irritation while minimizing skin exposure 5, 3
• Measure stoma size at each appliance change for the first 8 weeks as the stoma continues to change 3
• Heat the appliance with a hair dryer before application and lie flat for several minutes after to improve adhesion 3

Skin Preparation

Ensure the peristomal skin is completely dry before applying any pouching system. 3

For damaged skin 3:

• Apply fine dusting of stomal powder followed by skin sealant on any damaged peristomal skin before appliance placement
• Use paste or barrier rings around the stoma base to fill gaps and create a level surface 3

Common Complications and Prevention

Peristomal Skin Damage

The most frequent cause of peristomal skin damage is leakage of effluent onto the skin from poorly fitting appliances. 2

Skin excoriation is the most common complication (54.4% in one series), followed by surgical site infections (8.5%) 6

Other peristomal conditions include 2:

• Allergic contact dermatitis
• Fungal infections
• Folliculitis
• Peristomal pyoderma gangrenosum

Stoma Retraction

For retracted stomas 3:

• Use convex appliances to create pressure pushing the stoma outward
• Apply ostomy belt for consistent pressure
• Utilize paste or barrier rings around stoma base
• Monitor for secondary complications including peristomal skin breakdown

Persistent leakage causing significant financial hardship from frequent appliance changes and progressive skin damage may require surgical intervention. 5, 3

Critical Pitfalls to Avoid

Do not ignore persistent leakage, as it causes significant financial burden and progressive skin damage that may eventually require surgical intervention. 5

Avoid placing the appliance on moist skin, as this is a primary cause of seal failure. 5

Do not delay referral to WOC specialist if leakage persists despite initial interventions, as specialized expertise significantly reduces complications. 5

Avoid moving the stoma to a new location during surgical revision, as this creates significant risk of complications at the new site. 3

Patient Education Requirements

Patients must be taught 1:

• Recognition of high output/dehydration signs
• Food bolus obstruction prevention
• Appliance management techniques
• Dietary modifications
• When to seek urgent care

Many emergency patients needing a stoma will not see a stoma nurse preoperatively and may go several days before seeing one postoperatively, creating a critical education gap. 1

Special Considerations for IBD Patients

Risk factors for reduced nutritional status in CD patients include 1:

• Active disease
• Having an ileostomy
• Remnant small bowel length ≤230 cm

Stoma-related complications (fistula, retraction, stenosis) are more frequent in CD (36.8%) than UC (17.4%) (p<0.05). 1

Among CD patients, colostomies need earlier revisional surgery than ileostomies (p<0.05). 1