Colostomy

By: Jose Byron Dadulla-Evardone

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Definition
A

colostomy is a surgical procedure that brings a portion of the large intestine through the abdominal wall to carry feces out of the body.

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Purpose

A colostomy is created as a means to treat various disorders of the large intestine, including cancer, obstruction, inflammatory bowel disease, ruptured diverticulum, ischemia (compromised blood supply), or traumatic injury. Temporary colostomies are created to divert stool from injured or diseased portions of the large intestine, allowing rest and healing.
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 Permanent

colostomies are performed when the distal bowel (bowel at the farthest distance) must be removed or is blocked and inoperable. Although colorectal cancer is the most common indication for a permanent colostomy, only about 10–15% of patients with this diagnosis require a colostomy.
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Description
 Surgery

will result in one of three types of colostomies:

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End colostomy
 The

functioning end of the intestine, the section of bowel that remains connected to the upper gastrointestinal tract, is brought out onto the surface of the abdomen to form a stoma (an artificial opening) by cuffing the intestine back on itself and suturing the end to the skin.
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 The

surface of the stoma is actually the lining of the intestine, usually appearing moist and pink. The distal portion of bowel (now connected only to the rectum) may be removed or sutured closed and left in the abdomen. An end colostomy is usually a permanent colostomy, resulting from trauma, cancer, or another pathological condition.
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End Colostomy

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Double-barrel colostomy

This colostomy involves the creation of two separate stomas on the abdominal wall. The proximal (nearest) stoma is the functional end that is connected to the upper gastrointestinal tract, and will drain stool. The distal stoma, connected to the rectum, drains small amounts of mucus material. This is most often a temporary colostomy, performed to rest an area of bowel and to be later closed.
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Double-barrel colostomy

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Loop colostomy
 This

colostomy is created by bringing a loop of bowel through an incision in the abdominal wall. The loop is held in place outside the abdomen by a plastic rod placed beneath it. An incision is made in the bowel to allow the passage of stool through the loop colostomy.
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 The

supporting rod is removed approximately seven to 10 days after surgery, after healing has occurred that will prevent the loop of bowel from retracting into the abdomen. A loop colostomy is most often performed for the creation of a temporary stoma to divert stool away from an area of intestine that has been blocked or ruptured.
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Loop colostomy

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Preparation
 The

physician will outline the procedure, possible side effects, and what the patient may experience after surgery. The physician or an enterostomal therapist will explain the general aftercare to the patient before surgery, so the patient has all of the information necessary to make an informed decision about surgery and medical care.
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 Blood

and urine studies, along with various x rays and an electrocardiograph (EKG), may be ordered as necessary. If possible, the patient should visit an enterostomal therapist, who makes the decision about the appropriate place on the abdomen for the stoma and who offers pre-operative education on colostomy management.
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 To

empty and cleanse the bowel, the patient may be placed on a lowresidue diet for several days prior to surgery. A liquid diet may be ordered for at least the day before surgery. A series of enemas and/or oral preparations (GoLytely or Colyte) may be ordered to empty the bowel of stool.

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 Oral

anti-infectives (neomycin, erythromycin, or kanamycin sulfate) may be prescribed to decrease bacteria in the intestine and help prevent postoperative infection. On the day of surgery or during surgery, a nasogastric tube is inserted into the nose to connect it to the stomach to remove gastric secretions and prevent nausea and vomiting.
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A

urinary catheter may also be placed to keep the bladder empty during surgery, giving more space in the surgical area and decreasing the risk of accidental injury.

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Preparation

Post-operative care for the patient with a new colostomy involves monitoring of blood pressure, pulse, respirations, and temperature. The patient is instructed how to support the operative site during deep breathing and coughing, and given pain medication as necessary. Fluid intake and output is measured, and the operative site is observed for color and amount of wound drainage.
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 The

nasogastric tube will remain in place, attached to low-intermittent suction until bowel activity resumes. For the first 24 to 48 hours after surgery, the colostomy will drain bloody mucus. Fluids and electrolytes are infused intravenously until the patient's diet can gradually be resumed, beginning with liquids.
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 Usually

within 72 hours, passage of gas and stool through the stoma begins. Initially the stool is liquid, gradually thickening as the patient begins to take solid foods. The patient is usually out of bed in eight to 24 hours after surgery and discharged in two to four days.
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A

colostomy pouch or bag will generally have been placed on the patient's abdomen, around the stoma, during surgery. During the hospital stay, the patient and the caregivers will be educated on how to care for the stoma and the colostomy bag.
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 Determination

of appropriate pouching supplies and a schedule of how often to change the pouch should be established. Regular assessment and meticulous care of the skin surrounding the stoma is important to maintain an adequate surface on which to apply the pouch.
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 Patients

will be instructed in daily irrigation of the stoma about seven to 10 days after surgery. This results in the regulation of bowel function. Some patients with colostomies may need only a dressing or cap over the stoma and do not wear a colostomy pouch.
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 Often,

an enterostomal therapist will visit the patient at home after discharge to help with the patient's resumption of normal daily activities.

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Complications
Potential complications of colostomy surgery include:  excessive bleeding  surgical wound infection  thrombophlebitis (inflammation and blood clot in veins in the legs)

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 pneumonia  pulmonary

embolism (blood clot or air bubble in the lungs' blood supply)  cardiac stress due to allergic reaction to the general anaesthetic

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 if

the colostomy becomes blocked  if the stoma extends too far out from the abdomen, presenting the potential for physical damage or infection

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The physician should be made aware of any of the following problems after surgery: increased pain, swelling, redness, drainage, or bleeding in the surgical area  flu-like symptoms such as headache, muscle aches, dizziness, or fever  increased abdominal pain or swelling, constipation, nausea or vomiting, or black, tarry stools

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Stomal complications to be monitored include:

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Necrosis (death) of stomal tissue.
 Caused

by inadequate blood supply, this complication is usually visible 12 to 24 hours after the operation and may require additional surgery.
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Retraction

(stoma is flush with the abdomen surface or has moved below it). Caused by insufficient stomal length, this complication may be managed by the use of special pouching supplies. Elective revision of the stoma is also an option.
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Prolapse
 (stoma

increases length above the surface of the abdomen). Most often, this results from an overly large opening in the abdominal wall or inadequate fixation of the bowel to the abdominal wall. Surgical correction is required when blood supply is compromised.
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Prolapse

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Stenosis

(narrowing at the opening of the stoma). Often, this is associated with infection around the stoma or scarring. Mild stenosis can be removed under local anesthesia, while severe stenosis may require surgery for reshaping the stoma.
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Parastomal hernia

(bowel-causing bulge in the abdominal wall next to the stoma). Usually, this is due to placement of the stoma where the abdominal wall is weak or the creation of an overly large opening in the abdominal wall. The use of a colostomy support belt and special pouching supplies may be adequate. If severe, the defect in the abdominal wall should be repaired surgically, and the stoma moved to another location.
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Parastomal hernia

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Colostomy Care

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Definition
A

colostomy is a surgically created opening in the abdominal wall through which digested food passes. It may be temporary or permanent. The opening is called a stoma from the Greek word meaning mouth.

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 Stool

passes through the stoma into a pouch attached to the stoma on the outside of the abdomen. The pouch, stoma, and skin surrounding the stoma require care and maintenance by the patient or caregiver.

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Purpose
A

pouch is worn over a colostomy to collect the stool passed through the stoma. There are a variety of pouches available for use with a colostomy. Over time the patient can determine which pouch type best suits his or her needs.

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A

colostomy pouch is normally emptied one or more times daily. The pouch itself usually needs to be changed every four to six days. The stoma and surrounding skin need to be kept clean and sanitary.

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Precautions
 The

nurse attending to a colostomy should wash his or her hands before and after the procedure, as well as wear latex gloves while performing care.

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Description
A

pouching system is normally worn over a colostomy stoma. Pouches can be obtained from several different manufacturers in both disposable and reusable varieties. The enterostomal therapy ET nurse can be an invaluable resource when helping patients select a pouch system.
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 Colostomy

pouches may be either open ended or closed. Open-ended pouches require a clamp for closure. They can be drained simply and reused after they are emptied. Closed pouches are sealed at the bottom and are usually used by patients who irrigate their colostomies or who have a regular bowel elimination pattern.
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Two-piece pouch systems consist of a separate flange and pouch. The pouch has a closing ring that attaches to a matching piece on the flange. One-piece systems have a connected wafer and pouch that do not separate. The portion of the pouch that is applied to the abdomen is called a skin barrier wafer. Both two-piece and one-piece systems can be either closed or open ended
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 Some

patients with colostomies can irrigate their stomas using a procedure similar to an enema. This cleans the stool out of the colon through the stoma. A special irrigation system is used. Sometimes a special lubricant is used to prepare for the irrigation. Irrigating often leads to increased control over the timing of bowel movements.
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irrigation

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 Removing

the colostomy appliance requires gently pushing away the skin surrounding the stoma and pulling the appliance downwards. Adhesive remover wipes are available to help in the removal of the wafer.

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 The

bag is then discarded in an appropriate waste container. The stoma should be cleaned with lukewarm water and dried with a soft towel.

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 The

stoma and surrounding skin should be assessed. The stoma should be pink or red and moistlooking, and may bleed slightly when cleansed. The stoma normally decreases in size slightly during the first weeks after surgery.

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 The

opening in the wafer should fit snugly around the stoma. An opening that is too large will allow intestinal contents to leak onto the skin. Measuring guides come with the colostomy wafers so that the hole can be cut to the proper size. Skin barrier paste can be used to help create a better seal between the wafer and the patient's abdomen.
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 Various

skin preparation products are also available to help protect the skin under the wafer and around the stoma. They also aid in the adhesion of the wafer. Using the fingertips, gentle pressure should be applied to put the wafer in place.

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 After

the application of the barrier, the bag should be applied (if it is a two-piece system). If it is an open system, apply a clamp to the bottom of the new pouch.

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Preparation
 The

nurse should instruct the patient and caregiver(s) about the procedure before it is performed. Many people feel anxious and nervous when first dealing with an ostomy. Encourage the patient to ask questions, and explain all steps as they are performed.
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Aftercare
 The

nurse should assess the patient's tolerance of the procedure and response to teaching or education about the appliance.

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