stoma care

A stoma (Greek - pl. stomata) is an opening (a direct translation of the Koine Greek would be "mouth"), either natural or surgically created, which connects a portion of the body cavity to the outside environment. Surgical procedures in which stomata are created are ended in the suffix '-ostomy' and begin with a prefix denoting the organ or area being operated on.

In anatomy, a natural stoma is any opening in the body, such as the mouth. Any hollow organ can be manipulated into an artificial stoma as necessary. This includes the esophagus, stomach, duodenum, ileum, colon, pleural cavity, ureters, urinary bladder, and kidney pelvis.

One well-known form of an artificial stoma is a colostomy, which is a surgically-created opening in the large intestine that allows the removal of feces out of the body, bypassing the rectum, to drain into a pouch or other collection device. The historical practice of trepanation was also a type of stoma.

Stoma (Anatomy), a stoma refers to a mouthlike part. In particular it relates to a procedure involving the gastrointestinal tract (GIT) or gastrointestinal system (GIS). The GIT begins at the mouth or oral cavity and continues until its termination, which is the anus. This surgical procedure is invoked usually as a result of and solution to disease in the GIT. The procedure involves bisecting this tube, usually between the later stage of the small intestine (ileum) and the large intestine or colon, hence colostomy, and exiting it from the body in the abdominal region.

The point of exiting is what is known as the stoma. For greatest success and to minimise negative effects, it is preferable to perform this procedure as low down in the tract as possible, as this allows the maximal amount of natural digestion to occur before eliminating fecal matter from the body. The stoma is usually covered with a removable pouching system (adhesive or mechanical) that collects and contains the output for later disposal. Modern pouching systems enable most individuals to resume normal activities and lifestyles after surgery, often with no outward physical evidence of the stoma or its pouching system.
[edit] Examples of stomata

Dacryocystorhinostomy
Enteric:
Cecostomy
Colostomy
Duodenostomy
Ileostomy
Jejunostomy
Appendicostomy (see Malone antegrade continence enema)
Esophagostomy
Gastrostomy (also see percutaneous endoscopic gastrostomy)
Cholecystostomy
Choledochostomy
Sclerostomy
Thoracotomy
Tracheostomy
Urostomy (also see Ileal conduit urinary diversion)
Nephrostomy
Ureterostomy
Vesicostomy (cystostomy)


About stomas

A stoma is an artificial opening in your abdomen (tummy) to collect waste (either faeces or urine). Stomas to collect faeces connect to your bowel (intestine); stomas to collect urine connect to your ureter (the tube that carries urine from your kidneys to your bladder). This means you will no longer use a toilet when you open your bowels or urinate, as any waste products will pass into and be collected in a reservoir bag or pouch, on the outside of your body.

A stoma can be either temporary (and reversed later) or permanent, depending on the type of operation that has been done and how much of your bowel or urinary tract has been removed. The size and shape of your stoma will also depend on the type of operation you have had. A stoma will always be moist and may bleed if you touch it. It may protrude a few centimetres from your abdomen.
Types of stoma

The main types of stoma are:

ileostomy - an opening from the small bowel, to allow faeces to leave your body without passing through the large bowel
colostomy - an opening from the large bowel, to allow faeces to leave your body without passing through the anus
urostomy - an opening from the ureters, to allow urine to leave your body without passing through the bladder

Illustration showing the position of a stoma
What are the alternatives?

It's sometimes possible for your surgeon to create an internal pouch for the bowel waste out of bowel that has not been removed; this means you don't have to wear an artificial external pouch. This is known as pouch surgery. There are several different types, such as 'J' pouch, 'S' and 'W' pouch. They are complex operations and may not be suitable for everyone.

Rather than have a urostomy, it might be possible to reconstruct your bladder. However, this type of surgery isn't suitable for everybody - ask your doctor for information.
Managing your stoma

There are several different types of pouch available to fit over your stoma. They are all designed to fit discretely under your clothing, be easy to change, and not to leak or smell.

You will need to empty your pouch - a stoma nurse (a nurse who is qualified and specially trained to care for patients with a stoma) will show you how to do this. The way you empty it will depend on the exact type of stoma you have.

It's a good idea to get into a routine for changing the pouch. If you have an ileostomy or colostomy, you may find that at certain times of the day the pouch is more active than at others - such as shortly after a meal. Rather than change it then, choose a time when it's relatively inactive, such as first thing in the morning. You won't be able to control when you have bowel movements but the pouch usually has to be changed twice per day (but this can depend on the type of pouch you use).

Rather than use pouches, you may find that it's possible to flush out your stoma with lukewarm tap water so bowel movements can be timed to suit you. This is called routine irrigation and the aim is to only have bowel movements when the bowel is irrigated - not between flushings. Rather than wear a pouch you wear a colostomy 'plug' or 'bung' over the stoma instead.
Living with your stoma

You can expect to return to your normal daily activities after you have fully recovered from your stoma operation. You should be able to return to the same job. If your work is strenuous and involves heavy lifting or puts a strain on your abdominal muscles, you should first seek advice about wearing proper support. You can return to doing sports - even swimming, as there are special smaller bags you can wear and waterproof shields to protect the stoma.

Many people become much more active once they have a stoma, as their symptoms are relieved.

Occasionally, some of the bowel may stick out of the stoma (prolapse), or become narrowed. This can block the passage of faeces into the pouch. If this happens, you should see your stoma nurse or surgeon. Both of these problems can be corrected with surgery.

If you have a stoma of the bowel (a colostomy or ileostomy), you may notice that it sometimes moves, or 'wiggles' on its own. This is normal, and happens because your stoma is attached to your bowel, which squeezes and relaxes to allow digested food to move through.
Diet

In the first few months after your operation, your body will need to adapt to your shortened bowel and your stoma. Your stoma nurse will give you information on what's best to eat as you recover.

After you have recovered fully and the stoma is functioning normally, you should be able to eat a normal healthy diet.

If you have had a colostomy, your nurse or surgeon may advise you not to eat foods that may give you wind such as beans, broccoli and cabbage or fizzy drinks. He or she may also advise you to eat slowly and not to talk and eat at the same time, to prevent you swallowing too much air, which could cause wind.

Having a daily portion of apple sauce, cranberry juice, yogurt or buttermilk may help reduce any odour. Charcoal filters may be prescribed by your doctor if odour is problematic.

It's important to keep up your intake of fluids and eat foods that are rich in fibre to make sure you don't become constipated.
Skin care

Your stoma therapist or nurse will show you how to care for your stoma and the skin around it. A number of different protective pastes, membranes and powders are available. Your stoma therapist or nurse will show you how to use these, and what to do if your skin becomes damaged or sore.
Travelling

It's best to carry pouch spares in your hand luggage when you travel. You may need to carry a special certificate for carrying your pouch spares. If you're planning a long journey, it's best to irrigate your pouch just before you leave, and again when you arrive. If you're travelling to a country where the tap water isn't drinkable, you should use bottled water for your irrigation.
Help and support

Having a stoma can have a big impact on your body image. Specialist nurses and stoma therapists should be available to help you at each step of the process. This help may include assistance with the practical aspects, such as choosing the most suitable pouch system, emptying the pouch and looking after the skin around your stoma.

Just as importantly, your stoma nurse will support you through the emotional aspects of having a stoma. There are patient support groups, which can give you advice and support.

Stoma

A stoma is a surgical bypass of a natural conduit, a kind of "short circuit". It is practiced when the natural channel can no longer fulfill its role, as a result of trauma, disease or an ablation. Most common, feces or urine are collected in a pocket or bag. The stomas may be digestive, urinary ...
Stoma types

Colostomy refers to the process of connecting the colon to the abdomen so that the fecal matter is diverted through the incision usually performed on the stomach. Colostomy can be performed on any segment of the colon. On this hole called artificial stoma, the patient hangs a bag for single use to receive fecal matter.
Ileostomy - similar to the colostomy but the ileum is connected to the abdomen. The feces collected are much more liquid and coros for colostomy.
Tracheostomy - an opening in the trachea (front of the neck)
Urostomy - means connecting ureters with a segment of ileum to the abdominal wall, urine is collected in a pocket instead of the bladder.
Vasovasostomy - the reverse of vasectomy

Stoma care

How to take care of your stoma? ... read more here: Stoma care

Try to choose an outfit that will not affect the collection bag, or the stoma.
You do not need a special diet, just be careful at some foods.
Follow the basic rules of hygiene.
Life with stoma is not hard if you are well informed and know how to take care of the stoma.
If you encounter difficulties, do not be afraid to seek advice from people more informed than you, nurse, doctor...
Nothing should prevent you from finding a normal family life.
Recreation with stoma must be as normal as possible.
Once you feel better, we can only encourage you to resume a social life comparable to what it was before surgery.
You can travel as much as you want , just pack some stoma care tools that must be always in close reach.
Whether by car, plane or other means of transport, you can move without any restriction on destination, your stoma will not affect this ...
You can swim in the sea or the pool after a few months after the stoma surgery.
You can make the toilet of your stoma when you change outfit.
Sometimes the stoma may bleed easily so a learning period is necessary to acquire the skills to care for your stoma.
Baths and showers are no problem, the devices are waterproof.
Stoma or not, you must keep your style. You can adjust the bag to suit your daily activities (sports, travel, work...).
Eating at regular hours, calmly and slowly is recommended.
Drink a lot and regularly during the day (at least 1.5 to 2 liters per day).
Eat a balanced diet. Learn to recognize foods that give you gas, accelerate or slow down your transit.
In case of constipation or diarrhea, drink plenty of fluids.
Sport is compatible with a stoma and very recommended.
Avoid combat sports like boxing, karate, wrestling because this can easily damage the stoma.

Stoma picures

...more pictures here Stoma pictures
Stoma Pictures Stoma Pictures Stoma Pictures Stoma Pictures
Stoma care pictures

...more pictures here Stoma care pictures
Stoma diet Stoma diet Stoma diet Stoma diet
Stoma bag and stoma pouch pictures

...more pictures and information about stoma bag here Stoma bag
Stoma bag Stoma bag Stoma bag Stoma bag
Stoma care - I heard the following help :

Ispaghula husk - help in constipation.
Magnesium hydroxide - also helps in constipation.
Loperamide - helps in diarrhea.
Kaolin and morphine - help in diarrhea.
Codeine phosphate - increases the amount of water absorbed resulting in more solid feces.

Many people live now a healthy worry-free life after recovering from this disease and you can too. You can fully recover from this!!! Just learn a few about your problem and be an optimistic and courageous spirit. I wish you success!

Stoma Care

An ostomy is a surgically made opening from the inside of an organ to the outside.1 Stoma is the greek for mouth or opening. The stoma is the part of the ostomy attached to the skin. A stoma bag is then attached to the opening, in the case of colostomies, ileostomies and urostomies, so that either faeces or urine drain into this bag. There are various types of ostomies, for example:

Colostomy - opening from the large intestine to the abdominal wall so faeces bypass the anal canal.
Ileostomy - opening from the small intestine to the abdominal wall so faeces bypass the large intestine and the anal canal.
Urostomy - connection between the urinary tract and abdominal wall leading to a 'urinary conduit' so urine passes straight into a stoma bag and thus bypasses the urethra.
Gastrostomy and jejunostomy - openings between the stomach and jejunum respectively, and the abdominal wall, used predominantly for enteral feeding tubes.

Reasons for stomas

Gastrointestinal stomas are used in various disorders, e.g. inflammatory bowel disease, neoplasia, and diverticular disease.
Urostomies are more rare and are usually used following invasive neoplasia of the bladder or prostate.
Stomas may be temporary or permanent. Temporary stomas are usually reversed at a later date, usually allowing the blind loop of intestine to recover.

Patient preparation

Once a decision is made for a stoma, patients will be introduced to the stoma nurse specialist. The role of the nurse specialist should not be underestimated. They can provide counselling as well as information on the following:
The stoma procedure.
Practical aspects, e.g. types of stoma bags and various equipment available.
Reassurance that life can continue as normal - including bathing, showering and swimming (adhesive is waterproof).
How to change bags.
How to detect and manage the most common problems, e.g. bleeding on changing bags.
A really important part of planning patients for stomas is to ensure the site is appropriate. Poor siting leads to a stoma which the patient has difficulty in changing and cleaning. This leads to increased risk of skin, and other, complications.2
Once patients are discharged they are usually supported within the community by their GP and district nurses, especially in the initial period of adjustment.
Bags must not be restricted by clothing or waistlines.
Faeces and urine are usually flushed down the toilet - but the bags must not be discarded by flushing. Ileostomies and urostomies usually have features which allow the contents to be drained.

Features of a healthy stoma

When inspecting a stoma the presence of the following indicates a healthy stoma:

Stoma should be above the skin level.
Red and moist stoma (pallor may suggest anaemia, dark hue may represent ischaemia).
No separation between the mucocutaneous edge and the skin.
No evidence of erythema, rash, ulceration or inflammation in the surrounding skin.

Some problems associated with stomas
Psychological aspects

Having a stoma is a major event and patients can become very anxious and depressed. Adequate counselling is vital and this may need to include mental health specialists. Thus, good preparation with visual aids, e.g. pictures and written information, is crucial. Introducing potential patients to those who have already undergone the procedure is a valuable method.
Quality of life can deteriorate for patients following stoma procedure. The first few weeks post-stoma are the most vital.3 Patients may also have difficulty managing their stoma around their life, e.g. going out shopping and needing to change the stoma bag without adequate facilities. This can add to a low mood. Supportive family and friends are essential and may help in situations like this.
Stoma bags will also have an impact on body image and intimate relationships may suffer.3,4 It is good practice, therefore, to enquire about work and psychosocial aspects with patients.
During the first few weeks following the formation of a colostomy or ileostomy, patients may experience sudden urges to defecate. This is known as the 'phantom rectum' and can be very distressing for patients. Reassurance and support are helpful.

Changes in faeces

There may be changes to the amount and consistency of faeces.1 With ileostomies, faeces are produced about 4 hours after a main meal, whereas, with a colostomy, faeces are produced the following morning. Ileostomies are associated with increased output. Often patients have to change their diet to control wind and malodour, e.g. that caused by fizzy drinks and fish respectively. Flatus filters are also available.
Leakage of the contents of the stoma bag can occur and can make patients very distressed. Recurrent leakage can lead to skin inflammation from contact.

Stomas and skin problems

The skin at the site of the stoma can become erythematous and fissured or can develop an allergic reaction to the materials used in stoma equipment.
Various seals are available which cover and protect the opening. Similarly, hypoallergenic products are available for use in patients with stomas, e.g. lotions and cleansing wipes.

Stomas and dehydration

Ileostomies usually have a very high output and thus there is a risk of dehydration. Patients need to have a good intake of fluid and take an extra 1 litre above the usual. (However, advise the patient to avoid fizzy drinks and beer as these may cause flatulence.)
Bleeding from the stoma

It is common for there to be some bleeding from the stoma site following bag changes.5 This simply requires reassurance.
Bleeding needs to be distinguished from luminal bleeding which may represent underlying disease, e.g. flare-up of inflammatory bowel disease.
A more rare cause of bleeding is portal hypertension in patients with liver disease. They may have dilatation of cutaneous veins around the stoma site.

Stoma exit-related problems

This includes prolapse, narrowing or blockage of the stoma. Stenosis presents with ribbon-like stools and excessive high-pitched wind. These conditions require surgical correction.
The mucocutaneous junction may become detached - partially or fully. Simple good wound care should lead to reattachment.
Patients can also develop parastomal hernias - usually years later. Hernias can be managed conservatively to begin with, followed by surgery if resolution is not achieved.

Stomas in special circumstances
Stomas and travelling

Wind can become worse for patients when they travel in aircraft. The change in pressure within the cabin can lead to large amounts of wind being passed. This can be exacerbated by drinking fizzy drinks and beer.
Stomas and sports

Caps are available that will block off the stoma for patients during sporting activities.
Medicines that might need to be prescribed for patients with stomas

Most patients will eventually self-manage their stomas. They can usually alter any output-related problems by changing their diet. However, sometimes medication will be needed to relieve problems. These include:

For relief of diarrhoea, e.g. loperamide, opiates, codeine phosphate.
For relief of constipation, e.g. magnesium hydroxide, ispaghula husk (not for patients with ileostomies as it increases salt and water loss).

Document references

Hyland J; The basics of ostomies. Gastroenterol Nurs. 2002 Nov-Dec;25(6):241-4; quiz 244-5. [abstract]
Ostomy Wound Management; Part 1: Assessment and Management of Stomal Complications: A Framework for Clinical Decision Making
Brown H, Randle J; Living with a stoma: a review of the literature. J Clin Nurs. 2005 Jan;14(1):74-81. [abstract]
Simmons KL, Smith JA, Bobb KA, et al; Adjustment to colostomy: stoma acceptance, stoma care self-efficacy and interpersonal relationships. J Adv Nurs. 2007 Dec;60(6):627-35. [abstract]
Ostomy Wound Management; Part 2: Assessment and Management of Stomal Complications: A Framework for Clinical Decision Making

Internet and further reading

Stoma care, Irishhealth.com; Provides frequently asked questions and answers to common problems that might be encountered

Acknowledgements EMIS is grateful to Dr Gurvinder Rull for writing this article. The final copy has passed scrutiny by the independent Mentor GP reviewing team. ©EMIS 2011.
Document ID: 2805
Document Version: 24
Document Reference: bgp187
Last Updated: 29 Jul 2010

The authors and editors of this article are employed to create accurate and up to date content reflecting reliable research evidence, guidance and best clinical practice. They are free from any commercial conflicts of interest. Find out more about updating.

stoma indication
INDICATIONS AND COMPLICATIONS OF INTESTINAL STOMAS –
A TERTIARY CARE HOSPITAL EXPERIENCE
QAMAR A. AHMAD,1 M. KAMRAN SAEED,1 MAH JABEEN MUNEERA2
M. SARFRAZ AHMED1 AND KAMRAN KHALID3
1Department of Surgery, Services Institute of Medical Sciences / Services Hospital
2Department of Anatomy, Rashid Latif Medical College, Lahore
3Department of Surgery, Quaid-e-Azam Medical College / Bhawal Victoria Hospital, Bhawalpur
ABSTRACT
Introduction: An intestinal stoma is an opening of intestine on the anterior abdominal wall made surgi-cally. The commonly performed procedures include colostomy and ileostomy. The purpose of the present study was to identify indications for commonly performed intestinal stomas and to study complications related to it.
Subjects and Method: An observational study was carried out in Services Hospital Lahore, over a period of two years from Feb. 2007 – 09. A total of 85 patients needing intestinal stomas, ileostomy or colostomy, were included in the study. Patients under 12 years, with enterocutaneous fistula and urinary conduits were excluded from study. Indications, immediate and late complications of stomas were recorded. Reversal of stoma usually performed after 12 weeks and complications of reversal were also recorded.
Results: Majority (73%) of patients were males. There were 36 ileostomies and 49 cases of colostomy mak-ing a total of 85 patients. Main indications of Ileostomy were intestinal tuberculosis (58%), enteric perforation (31%) and penetrating injuries (5.5%). Colostomy was mostly required in penetrating injuries (33%), blunt trauma (23%) and intestinal obstruction (28%). In a total of 35 stomas local complications appeared in 54 (41.77%). General problems included anxiety, psychological and social isolation. Skin exco-riation and ulceration were the most common (25%); they were worse in ileostomy than colostomy. In laparotomy wound infection (9.4%), stoma diarrhea (7%), stoma retraction (6%) and prolapse (6%) were other notable comp-lications. A mortality rate of 1.6% was found in cases of ileostomy. Hospital admission ranged from 10 – 62 days. 62 stomas including 25 ileostomies and 37 colostomies were closed on an ave-rage of 3 months after primary operation. There were 9 cases of wound infection, three anastamotic leak-ages and a single mortality (1.6%) in the stoma reversal group.
Conclusion: Common indications for intestinal stomas were abdominal trauma, intestinal tuberculosis and enteric perforation. Main complications included local skin problems, stoma diarhoea, prolapse and retraction. Early identification and treatment of tuberculosis and enteric fever can reduce stoma forma-tion and its associated complications.
Key words: Colostomy, Ileostomy, Indications, Complications.
INTRODUCTION
An intestinal stoma is an opening of intestine on the anterior abdominal wall made surgically.1 The com-monly performed procedures include colostomy and ileostomy. Littre of Paris was the first to make a ve-ntral colostomy in 1710 for a baby with imperforate anus.2 In World war I, a mortality rate of 60% for primary repair of colonic injuries dropped to 30% in World war II due to the introduction of colostomy.3 Between 1893 to 1913, ileostomy was suggested for treating of small bowel obstruction, peritonitis due to ruptured appendix and appendicular abscess.4 Shock, marked blood loss, significant faecal conta-mination, associated injuries, time till presentation and multiplicity of injury are important factors favouring stoma formation than primary repair.5 However, the number of abdominal stomas made each year is declining. This decrease in ileostomies is more marked in UK, less than 100,000 patients now have an ileostomy.6 Stoma may serve the pur-pose of decompression, lavage, diversion and exte-riorisation. It may be temporary or permanent. Ma-jor indications of ileostomy include diffused bowel injury which precludes primary anastamosis like lo-ngstanding peritonitis intestinal obstruction, radi-ation enteritis ischemia and inflammatory bowel di-seases and rectal causes. Colostomy is employed in colonic obstruction (primarily due to cancer of dis-tal colon / rectum), perforation with peritonitis, rec-tovaginal fistulas and perianal sepsis.7
A troublesome stoma produces social, domestic and psychological upsets. These can be early inclu-

QAMAR A. AHMAD, M. KAMRAN SAEED, MAH JABEEN MUNEERA et al 145
Biomedica Vol. 26 (Jul. - Dec. 2010)
ding metabolic derangements, skin irritation, ischaemia
and stoma retraction. Late complications are
parastomal hernia, prolapse and stenosis. A thorough
preoperative preparation with special reference
to nutritional status, attention to the operative details
on timely management of complications usually
give gratifying results.8
In the present study, an attempt was made to
identify common indications and complications associated
with intestinal stoma in a tertiary care setup.
This insight will help us decrease the problems
associated with this commonly performed general
surgical procedure.
MATERIALS AND METHODS
It was a descriptive observational study carried out
in a surgical unit of Services Hospital Lahore, over
two years, from Feb. 2007 – 09. Eighty five patients
were selected using a convenient sampling. In them
some sort of intestinal stoma like ileostomy or colostomy
were included in the study. Patients under 12
years with enterocutaneous fistula and urinary conduits
were excluded from the study. Data was collected
on proformas. On arrival in emergency / OPD,
routine lab tests were performed. Final diagnosis
and operative procedure were decided by a surgeon
who then operated. Operative findings, procedure
done, immediate and late complications were recorded.
Final diagnosis was made after a report of histopathology.
The details about stoma, appliances,
complications and its management were recorded.
Usually Hollister or Convatec colostomy bags with
wafers and Stomahesive paste was used and bags
were applied by a trained doctor or a dispenser. During
stay in the ward, attendants were briefed about
management of stoma and related problems. Hospital
stay and patient’s follow up in out – patient clinic
at 1, 6 and 10 weeks were carried out. Reversal
of stoma after proper gut preparation was done after
12 weeks on elective list. Any associated complications
were also recorded.
In loop colostomies and ileostomies, either perforation
was exteriorised as such (posterior gut wall
intact) or posterior wall repaired and then exteriorised
at the same place. The afferent limb of loop ileostomy
was everted to minimise local skin complications.
Double barrel ileostomy was essentially an
end ileostomy with mucous fistulae (two ends at
same site) done after limited right hemicolectomy
(Table 1).
RESULTS
There were 23 (27%) females and 62 (73%) males
ranging from 12 – 70 years of age, commonest age
group for ileostomies was 12 – 20 years and 21 – 30
years for colostomies. There were 36 cases of ileostomy
and 49 cases of colostomy in the study (Fig.
1). About 56 (66%) stomas were made in emergency
and 29 (34%) in main operating theatres. Hospital
stay ranged from 10 – 62 days.
A total of 62 stomas including 25 ileostomies
and 37 colostomies were closed on an average after
3 months of primary operation. Twenty five Ileostomies
were reversed with 4 cases of wound infection
and two cases of anastamotic leak (intestinal tuberculosis).
Eleven patients lost to follow by the end of
study. There were 37 patients of colostomy reversal
including having 7 Hartman’s procedure. There were
5 cases of wound infection and an anastamotic
leak. There was a single mortality of an old patient
with Hartman’s colostomy reversal.
Seven end colostomies did not require reversal,
whereas 5 cases; (3 Hartman’s procedure and 2 loop
colostomies) lost to follow up.
0%
10%
20%
30%
40%
50%
60%
Types
colostomies
ileostomies
DISCUSSION
Faecal diversion remains an effective option to treat
a variety of gastrointestinal and abdominal conditions.
9 Ileostomy and colostomy are commonly
made intestinal stomas in surgery. In the present
study main indications and complications of these
common intestinal stomas were identified and discussed.
Males were three times more common to have
stoma than females. Compared to ulcerative colitis
in western world, the main indications of ileostomy
were intestinal tuberculosis (58.4%) and enteric
perforation (30.6%).7 This was in contrast to a study
reported from Karachi in which main indication was
typhoid perforation, accounting for two third of all
cases. Other less common included iatrogenic perforation,
rectal cancer, tuberculosis, blunt abdominal
trauma and anastamotic leakage.10 Tuberculous
abdomen is quite common in this part of the world.
The incidence of perforated tuberculous ulcer in
operated cases varies from 10.5 – 39% whereas the
incidence of intestinal stricture and ileoceacal mass
were 66% and 20% respectively.11 In the present
study, loop or double barrel ileostomy were procedures
of choice in perforated tuberculous ulcers or
ileoceacal mass with stricture formation.
Fig. 1: Types of Stomas.
146 INDICATIONS AND COMPLICATIONS OF INTESTINAL STOMAS – A TERTIARY CARE HOSPITAL EXPERIENCE
Biomedica Vol. 26 (Jul. - Dec. 2010)
Typhoid ileal perforation usually occurs in 2nd or 3rd week of illness. Simple as compared to len-gthy surgery improves survival.12 In the present study, loop ileostomy for multiple typhoid perfo-rations and simple closure with proximal ileosto-my were performed. The high incidence of unre-cognized abdominal tuberculosis and typhoid lea-ding to acute abdomen in our subcontinent is alar-ming and requires further research.
In case of colostomies, main indication was penetrating injury (32.6%), representing increas-ing violence in our society. (Table 2) untrained midwives. Blunt trauma by roadside accidents res-ulted in 22.4% colostomies. In a report by Bugis et Table 1: Type of ileostomies and colostomies.
Type
Patients
Percent
Ileostomies
n : 36
Loop Ileostomy
28
78
Double barrel
8
22
Colostomies
n : 49
Loop Colostomy
29
60
Colostomy with Mucus fistula
3
06
Hartman’s procedure
10
20
End Colostomy distal gut encised
7
14
al,3 blunt trauma resulted in 2 – 15% colonic injuries. In the present study colostomy was made in 14% cases of anorectal malignancy, 12% sigmoid volvulous and only 2% cases of adhesive obstruction study. This is in com-parison to a study done by Memon et al5 and they reported colostomy formation in 9.7% cases of acute intestinal obstruction.5 Stomas have risks and costs of their own in-cluding local, systemic complications and a second hospitalisation for closure. Major complications like sepsis, intraabdominal abscesses, wound infection or dehiscence and pneumonia are important indicators of clinical outcome but gut related complica-tions are often used to gauge effectiveness and risks of gut procedures.
In the present study 35 stomas (42%) developed 54 stoma related complications (Table 3). In one patient with ileostomy diarrhoea presented late and died within a few hours due to dehydration and electro-lyte imbalance. An ileostomy prolapsed (Fig. 2) appeared at 2.5 months and stoma reversed electively. Excoriation of skin and ulceration (25%) were the most common problems, worse in ileostomy than in colo-
Table 2: Indications of stomas.
Indications of Stoma
Patients
Percent
Ileostomy
n = 36
Penetrating injury (gunshot)
2
5.5
Intestinal Tuberculosis
21
58
Typhoid ileal perforation
11
31
Diversion (Carcinoma Colon)
2
5.5
Colostomy
n = 49
Injury
(a) Blunt Injury (Trafic accidents)
11
23
(b) Penetrating Injury (stab / firearm)
16
33
(c) Others
i) Iatrogenic colonic injury
3
6
ii) Anal sphincter injury
2
4
iii) Rectal Foreign body
2
4
Intestinal Obstruction
(a) Sigmoid Volvulus / Adhesive
6+1 = 7
14
(b) Anorectal malignancy
7
14
Rectovaginal fistula
1
2
stomy. Mostly patients were worried regar-ding frequent bag change and local skin problems due to financial constraints and lack of proper stoma care backup. Painful oozy skin with ulceration hinder ostomy bag application and poses problems in ha-ndling ostomy effluent.
This was in accordance with a study performed on 150 patients and local skin problems were there in 24 (16%) patients. Stoma stenosis in 9 (6%) and prolapse in 7 (4.6%) patients.13 Early application of sto-mahesive methyl cellulose paste with app-ropriate size bag were used to avoid it. Management included Zinc oxide paste,Table 3: Comparison of stoma related problems.
No.
Complications
Ileostomy
Colostomy
n =36
%
n =49
%
1.
Stoma bleeding
1
2.7
3
6
2.
Stenosis
-
-
1
2
3.
Necrosis
-
-
1
2
4.
Retraction
3
8.3
2
4
5.
Local skin problems
14
39
7
14
6.
Lap. wound infection
5
14
3
6
7.
Prolapse
3
8.3
2
4
8.
Parastomal Hernia
-
-
2
4
9.
Stoma Diarrhea
6
16.6
-
-
QAMAR A. AHMAD, M. KAMRAN SAEED, MAH JABEEN MUNEERA et al 147
Biomedica Vol. 26 (Jul. - Dec. 2010)
Fig. 2: Prolapsed Ileostomy.
Rashnil cream, egg white and keeping it dry till the ulceration is healed. Proper stoma care requires pa-tient training and services of stoma care specialist.
Most of the complications in the present study appeared in stomas constructed by residents or less experienced senior registrar in emergency. A sur-geon trained in stoma formation observing all tech-nical details usually give good results.14 In reversal of 62 stomas, these were three anaestomatic leakage and nine cases of wound infection. This was in acco-rdance with a study that showed a morbidity of 16% including extra abdominal complications.15 There was one mortality not related to closure, but occur-ring due to comorbid conditions.
In conclusion; main indications of stoma inclu-ded abdominal trauma, intestinal tuberculosis and enteric perforation. Important complications inclu-de local skin problems, stoma diarrhoea, prolapse and retraction. Avoidance of trauma, early identifi-cation and treatment of tuberculosis and enteric fever can reduce stoma formation and its associated complications.
ACKNOWLEDGEMENTS
The authors thank the administration of Services Institute of Medical Sciences to provide facilities to work for this project.
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