Ileostomy or colostomy care and complications
Executive Summary
This document provides a comprehensive synthesis of the management, patient education, and potential complications associated with ileostomy and colostomy creation, based on the UpToDate article "Ileostomy or colostomy care and complications." Successful patient adaptation hinges on preoperative preparation, including site selection by a specialist nurse (WOCN/enterostomal therapy nurse), and ongoing individualized education. Routine care focuses on proper pouch system management to contain effluent and protect peristomal skin, alongside dietary modifications to control gas and stool consistency.
Ileostomy patients face specific challenges, primarily the high risk of dehydration, which affects up to 30% of patients post-loop ileostomy. Management requires a significant increase in daily fluid intake (500-750 mL above normal) and strategies to manage high ostomy output, including soluble fiber and antimotility agents like loperamide. Colostomy patients, conversely, are more focused on preventing constipation through adequate fiber and fluid intake, with colon irrigation being an option for those with distal colostomies to achieve predictable bowel movements.
Complications are frequent, with an incidence rate of 14 to 79 percent. These are categorized by timing, with early complications (<3 months) including stomal ischemia/necrosis and mucocutaneous separation, and late complications (>3 months) including parastomal hernia, stomal prolapse, and stenosis. Peristomal skin problems are the most common complication and can occur at any time, stemming from mechanical trauma, effluent exposure (dermatitis), infections, or inflammatory conditions like pyoderma gangrenosum. Effective management is multifaceted, often requiring a combination of patient education, specialized products, medication, and, in some cases, surgical revision.
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1.0 Introduction and Patient Adaptation
An ileostomy or colostomy may be created temporarily or permanently to manage a wide range of pathologic conditions. The anatomic location and type of stoma (e.g., end, loop) significantly impact management, particularly concerning the volume and consistency of the effluent. While loop colostomies are larger and somewhat more difficult to manage than end colostomies, loop ileostomies are more challenging than end ileostomies due to frequent effluent emptying. With proper care and education, most patients can lead full, active lives.
1.1 The Importance of Patient Education and Counseling
Successful adaptation to an ostomy requires patients to master new skills for managing fecal elimination and to cope with the emotional impact of an altered body image. The process begins preoperatively whenever possible.
Individualized Education: A strong focus on both preoperative and postoperative education is a critical component of care.
Supportive Counseling: Pre- and post-operative counseling is beneficial for all patients, especially those having difficulty adapting. Involvement of an ostomy nurse specialist and ostomy support groups can significantly improve long-term outcomes and reduce complication rates.
1.2 Role of Specialist Nurses
The involvement of an enterostomal therapy (ET) nurse or a Wound Ostomy Continence Nurse (WOCN) is strongly associated with better patient outcomes.
Preoperative Stoma Site Selection: Marking the stoma site preoperatively by a specialist nurse is linked to fewer ostomy-related complications (e.g., leakage, dermatitis), improved patient ability to care for the ostomy, and reduced healthcare costs.
Professional Guidelines: The American Society of Colon and Rectal Surgeons (ASCRS) and the Wound Ostomy Continence Nurse Society (WOCN) have published position papers to guide proper stoma site marking.
2.0 Routine Ostomy Management
The primary functions of an ostomy pouching system are to contain effluent, contain odor, and protect the skin around the stoma (peristomal skin). Systems are available in one-piece and two-piece configurations.
2.1 Pouch Systems and Application
One-Piece Systems: Feature a skin barrier fused directly to an odor-proof pouch. They offer simplicity and flexibility.
Two-Piece Systems: Consist of a skin barrier with a flange or adhesive landing zone to which a separate pouch is attached. This allows the pouch to be changed without removing the skin barrier each time.
Pouch Placement: Proper pouch adherence is critical to minimize leakage and protect the skin. Key strategies include:
System Selection: Choosing a system that conforms to the patient's abdominal contour. A flat pouch with a rigid flange requires at least 4 cm of flat surface, while a convex pouching system is better for stomas in concave areas.
Sizing: The protective skin barrier opening must be sized to minimize skin exposure. As stomas change shape postoperatively, this may need frequent adjustment initially.
Adjunctive Products: Adhesive agents, skin prep, skin barrier paste, or barrier rings can improve pouch fixation and prevent irritation.
Barrier Wafers: Ileostomy patients, whose effluent is rich in proteolytic enzymes, must exercise particular caution, using barrier wafers or rings to prevent skin exposure.
2.2 Pouch Emptying and Care
Odor and gas are common concerns, but modern pouches are odor-proof when sealed.
Emptying Frequency: The pouch should be emptied when it is approximately one-third full to prevent the weight from disrupting the seal.
Changing Frequency: The pouch should be changed one to two times per week, or as needed if signs of leakage or skin itching/burning occur.
Odor Control:
Keeping the pouch tail clean is essential.
Room sprays or pouch deodorants can be used.
Oral agents like bismuth subgallate (thickens stool, reduces odor) or chlorophyllin (slight diarrheal effect) can be effective. Bismuth subgallate is better suited for ileostomy or proximal colostomy patients, while chlorophyllin is more appropriate for those with a descending/sigmoid colostomy.
2.3 Dietary Management and Gas Control
Most patients do not require a special diet, but certain foods can influence the amount of gas and the consistency and odor of the effluent.
Gas-Producing Foods: The carbohydrate raffinose, found in beans, cabbage, cauliflower, broccoli, and asparagus, is poorly digested and leads to gas. Starches (potatoes, corn, noodles) and soluble fiber (oat bran, peas, beans) also contribute.
"Lag Time": Patients should be educated about the "lag time" between ingesting a gas-producing food and actual flatulence, which is typically two to four hours for an ileostomy and six to eight hours for a distal colostomy.
Gas Control Strategies:
Dietary Modification: Avoiding carbonated drinks, chewing gum, and drinking through straws can reduce ingested air.
"Muffling" Measures: Using layers of clothing or light pressure on the stoma can muffle the sound of flatulence.
Over-the-Counter Aids: Gas-reducing agents like Beano can help.
Vented Pouches: Pouching systems are available with vents and deodorizing filters.
3.0 Specific Considerations for Ileostomy Patients
The output from ileostomies, cecostomies, and ascending colostomies is typically high-volume (>500 mL/day) and contains digestive enzymes that are irritating to the skin.
3.1 Dehydration and Fluid Management
Dehydration is the most common reason for hospital readmission after ileostomy surgery, affecting up to 30% of patients after loop ileostomy creation.
Fluid Intake Recommendations: Patients with an ileostomy should be instructed to increase their daily fluid intake by at least 500 to 750 mL beyond the general recommendations. Average output for an ileostomy patient ranges from 500 to 1300 mL per day.
Fluid Choices: Water, broth, and vegetable juices are recommended. Sports drinks should be avoided as they can exacerbate stoma output and dehydration. The use of pediatric electrolyte solutions (e.g., Pedialyte) is preferable.
Monitoring: Patients must learn the signs of fluid-electrolyte imbalance: dry mouth, reduced urine output, dark urine, dizziness, fatigue, and abdominal cramping.
3.2 Managing High Ostomy Output
High ostomy output is defined as output greater than 1.5 L/day.
First-Line Management: This should include adding soluble, viscous, nonfermenting, gel-forming fiber, such as psyllium husk, to the diet. Insoluble fiber (e.g., wheat bran) can speed transit time and should be avoided.
Medical Management: For patients who do not respond to fiber, antimotility agents are required.
Loperamide is the initial drug of choice due to its over-the-counter availability and fewer side effects.
Other agents include diphenoxylate-atropine, codeine, and tincture of opium.
Anti-secretory agents (octreotide, proton pump inhibitors, H2 antagonists) may be added.
Bile acid binders like cholestyramine may worsen malabsorption and should not be used in patients with end ileostomies.
3.3 Food Blockage
Patients with an ileostomy have an ileal lumen of less than 1 inch (2.5 cm) where the bowel passes through the fascia, creating a risk for food blockage.
Cause: Large amounts of insoluble fiber can create an obstructing mass (bezoar).
Common "Offenders": Popcorn, coconut, mushrooms, black olives, stringy vegetables, corn, nuts, celery, foods with skins, dried fruits, and meats with casings.
Prevention: Patients should be instructed to consume potential offenders one at a time in small amounts, chew thoroughly, and monitor their response.
3.4 Drug Malabsorption
The small bowel is the primary site of drug absorption, so ileostomy patients are at risk for suboptimal absorption.
Medication Forms: Patients should be taught to take medications in forms of quick dissolution, such as liquids, gelatin capsules, and uncoated tablets.
Avoidances: Time-released and enteric-coated medications, as well as very large tablets, are likely to be incompletely absorbed. Patients should also avoid laxatives due to the risk of acute dehydration.
4.0 Specific Considerations for Colostomy Patients
Descending/sigmoid colostomies produce formed stool and do not contain digestive enzymes. There are typically no dietary restrictions.
4.1 Constipation Management
Patients should be taught to prevent constipation by maintaining adequate fiber and fluid intake.
Fiber: 20 to 35 g/day.
Fluid: At least 1.5 to 2 L/day.
Intervention: If constipation occurs, it can be managed with laxatives or irrigation. In severe cases, digital disimpaction by a trained clinician may be necessary.
4.2 Colon Irrigation
Routine irrigation is appropriate only for patients with distal colostomies (descending or sigmoid).
Purpose: To stimulate peristaltic activity and empty the colon on a routine schedule (usually daily or every other day), allowing for a "stool-free" interval of approximately 24 hours.
Procedure: Involves the instillation of 500 to 1500 mL of tap water into the stoma.
Benefits: Many patients who successfully use irrigation only need to wear a small pouch or "cap" over the stoma. There is no evidence that routine irrigation leads to bowel dependence or has adverse effects.
5.0 Lifestyle and Physical Activity
Patients can be reassured that most daily activities can be resumed with minimal, if any, modifications.
Daily Activities: Bathing and showering can be performed with the pouch on or off.
Sports: Most sports activities can be resumed, with the exception of extreme contact sports that could damage the stoma. A belt or binder can help secure the pouch during vigorous activity.
Travel: Patients should be advised to take extra ostomy supplies and place them in carry-on luggage. Some airports offer private pre-screenings. When traveling, it is advisable to drink only bottled water if local water safety is unknown.
Sexual Health: The ostomy itself does not affect organic sexual function. However, if the ostomy was created as part of pelvic surgery or radiation, autonomic nerves controlling sexual function may be affected. Patients should receive counseling regarding sexual activity and partner response. Emptying the pouch beforehand is helpful, and commercial pouch covers, lingerie, or undergarments can be used to conceal and secure the pouch.
6.0 Overview of Stomal Complications
The incidence of stomal complications is high, ranging from 14 to 79 percent. Nearly half of all stomas eventually become "problematic."
Incidence by Stoma Type: Complications vary, with loop ileostomies having the highest complication rates, followed by end ileostomies, end colostomies, and loop colostomies.
Common Problems: Dehydration and skin irritation are most common for end and loop ileostomies. Parastomal hernia and retraction are the most common for end and loop colostomies. Prolapse is most prevalent in loop colostomies.
Classification: Complications are often classified by their time of onset.
7.0 Early Complications (Within 3 Months)
Early complications often result from suboptimal stoma site selection, patient factors (e.g., old age, obesity, poor nutrition), or underlying malignancy.
Stomal Necrosis: Incidence is as high as 14%. Caused by venous congestion or arterial insufficiency to the stoma. Critical assessment is required to determine the extent of necrosis. If it extends below the fascia, immediate surgical revision is necessary.
Stomal Bleeding: Minor bleeding from the stoma can occur postoperatively or with vigorous cleaning. Major bleeding is uncommon and may indicate a laceration from a poorly fitting appliance or the presence of peristomal varices, which require specialized management.
Stomal Retraction: Defined as a stoma that is 0.5 cm or more below the skin surface. The incidence is 1 to 40%. It leads to leakage and skin irritation. Management depends on the degree of retraction and may involve local wound care, convex pouches, or surgical revision.
Mucocutaneous Separation: Separation of the ostomy from the peristomal skin, occurring in 12 to 24% of patients. It results in leakage and skin irritation. Management involves filling the defect with absorptive material and protecting the surrounding skin.
8.0 Late Complications (After 3 Months)
Risk factors for late complications include duration of stoma, increases in intra-abdominal pressure (obesity, COPD), emergency surgery, and technical factors like an inappropriately sized aperture.
Parastomal Hernia: A common complication where intestines protrude alongside the stoma. Risk factors include obesity, poor abdominal muscle tone, and a large fascial opening.
Stomal Prolapse: The telescoping of the intestine out from the stoma. The incidence is 2 to 3% for an ileostomy and up to 30% for transverse loop colostomies. Risk factors include increased intra-abdominal pressure and a redundant loop of bowel. Uncomplicated prolapse can be managed conservatively with reduction, while complicated prolapse (ischemia, bleeding) requires urgent surgical intervention.
Stomal Stenosis: A narrowing of the stoma sufficient to interfere with function, with an incidence of 2 to 15%. It can occur early from edema or late from scarring. Mild stenosis may be managed with dietary changes, while clinically significant stenosis usually requires surgical correction.
9.0 Peristomal Skin Complications (Any Time)
Peristomal skin breakdown is the most common ostomy complication, occurring more frequently with ileostomies than colostomies due to the high-volume, alkaline, enzymatic output.
Mechanical Trauma: Patchy areas of irritated skin from repeated removal of adhesive products or overly aggressive cleaning.
Irritant Contact Dermatitis: Severely denuded skin caused by exposure to damaging effluent. It is most common in ileostomy patients. A properly fitting pouch is the best method of prevention.
Fungal Infection: Presents as a maculopapular rash with satellite lesions, common in warm, humid climates. Treatment involves antifungal powder (nystatin, miconazole).
Allergic Contact Dermatitis: Characterized by pruritus, erythema, and blistering corresponding to the area of contact with an offending product in the pouching system.
Parastomal Ulceration: A discontinuity of peristomal skin, usually related to an infected postoperative hematoma or intestinal fistula.
Granulomas: Red, moist, elevated lesions, often resulting from a retained suture. Treatment involves removing the irritant and applying silver nitrate.
Pyoderma Gangrenosum (PG): A rare neutrophilic dermatosis that causes painful skin ulcerations. It is a subtype of PG that occurs at stoma sites, often associated with inflammatory bowel disease (IBD). Diagnosis is one of exclusion. Management involves systemic or topical therapies (e.g., corticosteroids, tacrolimus, infliximab) and modified wound care. Surgical intervention may be required for severe cases.
10.0 Key Summary and Recommendations
Patient Education: Patients must be educated on adapting to their ostomy, managing their appliance, controlling gas and odor, and understanding dietary limitations. Specialist nurse involvement is key.
Managing Gas: Dietary modifications and over-the-counter aids can help. The "lag time" between food ingestion and flatulence is 2-4 hours for ileostomy and 6-8 hours for distal colostomy.
Managing High Ostomy Output: Ileostomy patients should increase fluid intake, supplement with soluble fiber, and may require antimotility agents to prevent dehydration.
Managing Constipation: Colostomy patients should ensure adequate fiber (20-35 g/day) and fluid (1.5-2 L/day). Colonic irrigation is an option for distal colostomies only.
Managing Complications: Nearly half of all stomas become problematic. Early complications (<3 months) include necrosis and separation. Late complications (>3 months) include hernia and prolapse. Peristomal skin breakdown is the most common complication at any time and requires meticulous care and proper pouching. Surgical revision may be necessary when an ostomy becomes dysfunctional.
