Can a retracted stoma in a patient with a history of gastrointestinal surgery, such as a colostomy (creation of an opening in the colon) or ileostomy (creation of an opening in the ileum), lead to peritonitis (inflammation of the peritoneum)?

Stoma Retraction and Peritonitis Risk

A retracted stoma does not automatically cause peritonitis, but it creates a significant risk for peritoneal contamination if bowel contents leak into the peritoneal cavity through the disrupted stoma tract. The key determinant is whether the bowel wall maintains its seal with the abdominal wall or if separation occurs allowing spillage.

Mechanism of Peritonitis Development

When a stoma retracts below the skin level, several scenarios can occur:

• Without tract disruption: The stoma may retract but maintain mucocutaneous continuity, causing local complications (skin irritation, leakage onto skin) without peritoneal contamination 1
• With tract separation: If retraction causes the bowel to separate from the abdominal wall, intestinal contents can leak directly into the peritoneal cavity, resulting in secondary peritonitis 2, 3
• Timing matters: Early postoperative retraction (before tract maturation at 7-10 days) carries higher peritonitis risk than late retraction when the tract is well-established 4

Clinical Presentation Distinguishing Local vs. Peritoneal Complications

Look for these specific signs to differentiate peristomal complications from peritonitis:

Localized peristomal complications (no peritonitis):

• Peristomal skin irritation and breakdown 1
• Difficulty with appliance adherence 4
• Visible stoma below skin level
• Localized tenderness without peritoneal signs

Peritonitis indicators requiring urgent intervention:

• Abdominal rigidity and rebound tenderness (present in 74-95% of peritonitis cases) 3
• Fever >38.5°C 3
• Tachycardia 3
• Hemodynamic instability 3
• Diffuse abdominal pain beyond the stoma site 3
• Leukocytosis with left shift 3
• Elevated lactate 3

Management Algorithm

For suspected stoma retraction with possible peritoneal contamination:

1. Immediate assessment: Examine for peritoneal signs (rigidity, guarding, rebound tenderness) 3

2. Imaging if peritonitis suspected: CT scan has the highest sensitivity and specificity for detecting peritonitis and can identify free fluid or air in the peritoneal cavity 3

3. If peritonitis confirmed:

   • Immediate surgical exploration is mandatory for unstable patients or those with diffuse peritonitis 1
   • Source control through laparotomy or laparoscopy to assess contamination extent 1
   • In stable patients with limited contamination: primary repair may be possible 1
   • In unstable patients or diffuse peritonitis: damage control surgery principles apply, potentially requiring Hartmann's procedure or resection with diverting stoma 1

4. If no peritonitis: Local stoma revision can be performed electively with enterostomal nursing support 5

Critical Pitfalls to Avoid

• Do not assume all retracted stomas cause peritonitis: Many cause only local skin complications that can be managed conservatively with wound care 1
• Do not delay imaging in unstable patients: While CT is ideal, unstable patients require immediate surgical exploration without imaging delay 1
• Recognize that obesity increases complication risk: Obese patients have 2.66 times higher odds of stoma complications including retraction 5
• Early involvement of enterostomal nursing reduces complications by 85% (OR = 0.15) and may prevent progression to serious complications 5

Special Considerations

The mortality from peritonitis secondary to bowel perforation or anastomotic complications ranges from 4-10% even with appropriate management 1. When peritonitis develops from stoma-related complications, outcomes depend heavily on:

• Time to diagnosis and intervention 3
• Adequacy of source control 3
• Patient physiologic reserve 1

Enterostomal nursing consultation should be obtained immediately for any stoma retraction to prevent progression to serious complications 5.