OSTOMY CARE

Vohra Wound Care Certification Course

Disclaimer: This presentation is for informational purposes only. Every patient and medical situation is unique, and medical decisions
should be based on standard of care and medical practices. Views expressed in this presentation are the sole opinion of the presenter.

Learning objectives:

1. Discuss the types of Fecal and Urinary Diversions and Management

2. Discuss the types of Continent Diversions and Management
3. Distinguish between Loop stoma, End stoma, Double-Barrel stoma, and Mucous Fistula
4. Identify Peristomal skin conditions and recommend appropriate management
5. Identify stoma complications and verbalize appropriate management
6. Recognize important factors to be included in caring for an ostomate
7. Explain resources available for patients with fecal and urinary diversions
8. The participant will be able to differentiate between the various ostomy appliances and supplies

Outline:

• Types of fecal diversion

• Types of continent fecal diversion
• Types of urinary diversion
• Ostomy appliances and supplies
• Stoma complications
• Peristomal skin conditions
• Resources for patients with fecal and urinary diversion
• Sources

Introduction1
Intestinal stomas are a means of temporary or permanent fecal diversion for various conditions, benign and malignant.
They are classified by the location of the bowel used to make the ostomy.

Types of fecal diversion1

End ostomy: The transected end of bowel is brought up to the skin to form an ostomy.

Loop ostomy: A loop of bowel is brought to the skin to form the ostomy.

Proximal end produces stool.

Distal end is a mucous fistula that allows the distal bowel to vent and produces mucous.

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Ostomy Care Vohra Post-Acute Physicians
Types of fecal diversion Colostomy
• Named by the portion of bowel that they are created from. I.e. ascending, transverse, descending, sigmoid
• May be end or loop in configuration
• Stool is more solid when compared to small bowel stomas

Small bowel stoma

• Named by the portion of small bowel that they are created from. I.e ileostomy is from the ileum, jejunostomy is
from the jejunum
• May be end or loop in configuration
• Stool is usually more liquid and patients are more at risk for dehydration

Types of continent fecal diversion 1, 2

Ileal pouch anal anastomosis:

Utilized when the colon and rectum have been surgically removed.

Ileum is created in to a neorectum (pouch) and anastomosed to the anus.

Patient typically have multiple bowel movements a day, approximately 5-8.

Kock pouch:

Utilized when the colon and rectum have been surgically removed.

Ileum is created in to a pouch that is attached to the anterior abdominal

wall and skin.

Continence is created with the use of a nipple valve. Defecation occurs

when the valve is intubated with a catheter.

Types of urinary diversion1

Ileal conduit:

Simplest form of diversion.

A segment of ileum is anastomosed to the ureters and the

ileum is brought to the skin as an ostomy.

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Ostomy appliances and supplies1

• One-piece vs two-piece appliance:

o Two-piece appliance can allow inspection of
stoma without removing whole appliance
• Types of appliance wafers:
o Flat: no additional profile on wafer
o Convex: wafer is built to exert inward force
around the peristomal skin and allow the
stoma to protrude further into the appliance,
decreasing incidence of leaks and skin
irritation

• Adjuncts:
o Stoma paste / powder protects skin from stool
o Moldable ring: helps form a seal between appliance and skin, thereby protecting the skin. It can also
be used for peristomal irritation

Choice of appliance

There is no one size fits all approach to appliance choice.

The decision should be based on appearance of stoma, patient’s habitus, patient preference, and provider’s clinical
judgement.

Stoma complications1, 3

Stoma necrosis:

• Occurs as a result of poor perfusion of the stoma, leading to

ischemia of the stoma and possibly necrosis
• Ischemia may be limited to the mucosa or be full thickness
• The depth of ischemia can be determined using the “test tube” test
• Test tube test:
o Insert a well lubricated test tube into the stoma
o Use flashlight to assess depth of ischemia
o If limited to above the abdominal fascia, may watch and
wait
o If below the level of the abdominal fascia, may require
surgical intervention to avoid intra-abdominal bowel
perforation/necrosis

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Stenosis:

• Tightening of the ostomy, can be at the fascial level or skin level

• Need for revision depends on symptoms and ability to adequately
pouch
• If the patient has symptoms of obstruction, surgical management
may be required

Stoma retraction:

• The stoma recedes to the level of the skin or sometimes below

• Need for revision depends on symptoms and ability to adequately
pouch
• If that patient is having stool leaking in to the abdomen, surgical
management will be required to revise the stoma

Prolapse:

• This is telescoping of the bowel from the stoma

• May cause obstruction or strangulation of the stoma
• May be observed if asymptomatic
• If causing symptoms, such as pain, or obstruction and/or strangulation, this will require surgical revision

Parastomal hernia:

• Accumulation of bowel in the subcutaneous tissue from the abdomen, around the stoma
• Can be observed if asymptomatic
• If symptomatic with signs of obstruction, abdominal pain, may require surgical management

Peristomal skin conditions1, 3, 4

Mucocutaneous separation:

• Characterized by the bowel pulling away from skin

• An early complication after surgery
• Treatment:
o Any fibrinous exudate should be cleansed away with saline prior to appliance application
o Barrier ointment must be used during placement of an appliance
o If there is drainage from the wound, fluid absorbing alginate dressing should be used

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Ostomy Care Vohra Post-Acute Physicians
Chemical irritation:

• Associated with leakage of stool on the skin as a result of poor

pouching
• Treatment:
o Adequate pouch application,
o Filler pastes
o And/or convex pouch

Candidiasis:

• Bright red lesions that are moist, develop under the pouch
• More common with ileostomies and immunocompromised patients
• Treatment:
o Proper pouching
o Topical antifungal powder

Pressure injury:

• Associated with convex pouch, stoma belt and parastomal hernias

• Treatment:
o If a firm convex pouch is used, switch to a flexible one
o Perform local wound care for ulcer

Granuloma:

• Occur at the mucocutaneous junction as a response to retained suture material

• Treatment:
o Probe the granuloma and remove remaining suture

Allergic / contact dermatitis:

• Rare, can occur in reaction to any ostomy product

• Treatment:
o Rule out offending agent by testing on an area of skin away from the stoma and assess for reaction
o Replace the offending agent with non-allergenic alternative
o Aerosolized topical corticosteroids can be used

Pyoderma gangrenosum:

• Painful peristomal ulcerations

• Associated with patients with IBD, autoimmune conditions, rheumatological and inflammatory conditions
• Treatment:
o Keep skin dry and using non-adherent dressings
o Promoting proper pouching
o Topical agents and intralesional corticosteroids have been used for treatment
o Most effective treatment is restoring intestinal continuity

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Ostomy Care Vohra Post-Acute Physicians
Pseudo verrucous lesions:

• Raised thickened skin around the stoma, associated with itching and bleeding
• Result from chronic contact dermatitis and prolonged moisture exposure
• Treatment:
o Proper pouching with adequate seal
o Topical silver nitrate for raised lesions, or steroid injections.

Resources for patients with fecal & urinary diversion

United Ostomy Association of America (UOAA)

Friends of Ostomates Worldwide

Crohn's and Colitis Foundation

Local area ostomy support group

References:
1. McGee, Michael F., and Peter A. Cataldo. "Intestinal stomas." The ASCRS Textbook of Colon and Rectal
Surgery. Springer, Cham, 2016. 971-1013.

2. Krane, Mukta K., Erin O. Lange, and Alessandro Fichera. "Ulcerative Colitis: Surgical Management." The
ASCRS Textbook of Colon and Rectal Surgery. Springer, Cham, 2016. 869-894.

3. Krishnamurty, Devi Mukkai, Jeffrey Blatnik, and Matthew Mutch. "Stoma complications." Clinics in colon and
rectal surgery 30.03 (2017): 193-200.

4. Steinhagen, Emily, Janice Colwell, and Lisa M. Cannon. "Intestinal stomas—postoperative stoma care and
peristomal skin complications." Clinics in colon and rectal surgery 30.03 (2017): 184-192.

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Ostomy Care Vohra Post-Acute Physicians