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 e.g.

• 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 stoma bag and thus bypasses the urethra.
• Gastrostomy and jejunostomy - openings between stomach and jejunum respectively, and the abdominal wall used predominantly for enteral feeding tubes.

• Gastrointestinal stomas are used in various disorders e.g. inflammatory bowel disease, neoplasia, 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.

• 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
  • How to change bags
  • How to detect and manage the commonest 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.

When inspecting a stoma the presence of the following indicate 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 mucocutaneous edge and the skin
• No evidence of erythema, rash, ulceration or inflammation in surrounding skin

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 under gone 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 is 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 defaecate. This is known as the "phantom rectum" and can be very distressing for patients. Reassurance and support is helpful.

Changes in faeces

• There maybe changes to the amount and consistency of faeces.¹ With ileostomies faeces are produced about 4 hours after a main meal, where as 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. (But advise 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 re-attachment.
• 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 and travelling

Wind can be worsened by patients when travelling 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.

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 increase salt and water loss)