management of a stoma

Last edited 09/2021 and last reviewed 10/2021

The patient's management of a stoma begins a few days after it has been formed: they observe the initial care and are gradually encouraged to take over. The skin around the stoma should be cleaned with water and dried thoroughly. If the stoma is of irregular shape, the patient must be shown how to cut the pouch flange to size.

To prevent a troublesome odour, specific foods, e.g. eggs and cheese, may need to be avoided. Alternatively, masking may be attempted by placing deodorant sprays and powders into the pouch. Flatus can be averted by avoiding specific foods and fizzy drinks, and using pouches with flatus filters.

Skin problems are commonly due to an ill-fitting pouch and these are correctable by teaching the patient correct application. This can be supplemented by minimal barrier cream massaged into the site. Leakage is frequently the result of a poorly-sited stoma, and local scars and skin folds may need to be filled with methyl cellulose bland paste

• over-granulation is the formation of nodular pink friable tissue as part of the healing process
  • is a common cause of bleeding and topical application of silver nitrate via a pen can be administered by the stoma team or an experienced clinician
• consider cutaneous manifestations of disease such as malignant deposits or fistulae and pyoderma gangrenosa in IBD
  • consider referral to a specialty team if appropriate
• bag leaks can be distressing to patients and lead to skin excoriation (more commonly from ileostomies where effluent is irritant)
  • specialist stoma nursing teams can offer valuable advice on device issues
    • however, reassure your patient that trial and error with devices is a completely normal part of the process of learning to live with a stoma
  • note that:
    • a wider adhesive section may be helpful in preventing leaks
    • warm bags will stick better than cold bags.
    • the bag can fill with gas, and the adhesive can be partially peeled back to release the pressure without complete removal, thus limiting skin trauma

A newly formed ileostomy usually functions within 24 h and produces 1200 mL of watery stool per day (500-2000 mL/day) (2)

• however, the amount of ileostomy output can be maintained at 300-700 mL/day, called ileostomy adaptation

Managing increased output:

• reasonable to aim for output of less than 1-1.5 L a day, and any increase from this or the patient's norm would be considered "high output"
  • note that Tsujinaka et al state "..When the amount of fluid from the stoma exceeds 1000-2000 mL/day, it is called high output stoma (HOS), which occurs in 16% of patients with stoma creation.."
• possible causes to consider include:
  • medication, change in diet, or infective causes can result in HOS; causes include:
    • partial bowel obstruction, intra-abdominal sepsis, prokinetic drugs (e.g., metoclopramides), sudden withdrawal of steroids or opiates, and enteritis with Clostridium difficile infection
    • diuretics, coexisting diabetes mellitus, and total proctocolectomy are the risk factors for HOS
  • incomplete bowel obstruction secondary to adhesions, hernias, and residue within the lumen
    • can present as watery output, much like overflow diarrhoea as a presentation for constipation
    • if a patient has associated vomiting or abdominal pain, seek urgent surgical review
• advice for management (1)
  • commence an anti-diarrhoeal agent even if you suspect infective causes
    • use orodispersible preparations to ensure absorption; start with 2 mg of loperamide four times a day, and escalate up to a maximum of 16 mg four times a day based on response
    • stool sample should be sent for culture (and include clostridiodes difficile as appropriate)
  • advise patients to drink oral rehydration solutions
    • eating marshmallows or jelly babies may thicken effluent, as gelatine utilises water within the bowel (1)
  • with respect to medications
    • consider switching to liquid or dissolvable preparations, and avoid modified release versions which may not be absorbed owing to fast transit while symptoms are ongoing
  • urgent referral to secondary care is indicated if:
    • high output is ongoing despite the measures described above, or,
    • blood results show evidence of electrolyte disturbance, or,
    • patient is clinically dehydrated

Management of decreased output:

• can range from less than the patient's normal output to absolute constipation
• trigger foods can lower stoma output
  • high fibre vegetables such as brassicas may contribute to bowel obstruction as the fibrous residue can block the bowel, and mushrooms and nuts are common trigger foods
  • consider referral to a dietician to discuss a low residue diet

Parastomal herniae, ileostomies that are flush with the skin and stomal prolapse, may all be managed by simple measures such as supporting belts and manual reduction, but ultimately, surgical correction is required

• a prolapse rarely represents an emergency but necrosis, ulceration, or a painful prolapse are reasons to refer urgently (1)
  • stoma prolapse is a full-thickness protrusion of the bowel through the stoma site, with incidence rate of 2%-3% in ileostomies and 2%-10% in colostomies (2)
    • transverse loop colostomies are most susceptible to stoma prolapse, with an incidence rate as high as 30%
    • endostomas have lower incidence rate than loop stomas
• parastomal hernias are common and can affect up to 40% of people with a stoma (1)
  • definitive management is to reverse the stoma, which is not always possible or appropriate as risks may outweigh benefits

Drainable pouches have their contents released directly into the toilet. Closed pouches are cut with scissors, their contents drained, and the residual pouch wrapped in newspaper, sealed in a plastic bag, and placed in the dustbin.

Reference:

• Strong C et al. Common intestinal stoma complaints. BMJ 2021;374:n2310
• Tsujinaka S, Tan KY, Miyakura Y, et al. Current Management of Intestinal Stomas and Their Complications. J Anus Rectum Colon. 2020;4(1):25-33. Published 2020 Jan 30. doi:10.23922/jarc.2019-032