Stoma care

An ostomy is a surgically made opening from the inside of an organ to the outside. Stoma is the Greek word 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 - eg, 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 to site a stoma, patients will be introduced to the stoma clinical 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 - eg, 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.¹

  • How to detect and manage the most common problems - eg, bleeding.

• 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.

• 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.

• Beefy red in colour indicative of good blood flow (pallor may suggest anaemia; dark hue may represent ischaemia).

• No separation between the mucocutaneous edge and the skin.

• Presence of a small amount of mucus and a moist inner surface.

• 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 (eg, pictures and written information) is crucial. Introducing potential patients to those who have already undergone the procedure is a valuable method. Videos based on patient experiences have proved effective.

• Quality of life can deteriorate for patients following stoma procedure. The first few weeks post-stoma are crucial. Patients may also have difficulty managing their stoma around their life - eg, 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. 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. With ileostomies, faeces are produced about four hours after a main meal, whereas with a colostomy, faeces are produced less frequently, with pouches needing emptying approximately 1-3 times per day.. Ileostomies are associated with thinner consistency and more frequent output compared to colostomies. Often patients have to change their diet to control wind and malodour - eg, 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 problems²

• 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, such as stoma rings, are available which cover and protect the opening. Similarly, hypoallergenic products are available for use in patients with stomas - eg, 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 fizzy drinks and beer should ideally be avoided as these may cause flatulence.

Bleeding from the stoma

• It is common for there to be some minor bleeding from the stoma site following bag changes. The stoma is very vascular and will easily bleed if knocked or trapped in the edge of the stoma appliance. This simply requires reassurance.

• Bleeding needs to be distinguished from luminal bleeding which may represent underlying disease - eg, 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.² 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 travelling²

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.

If driving or flying, if the stoma comes into contact with the seat belt, a stoma guard or belt extender can be used.

Stomas and sports

Caps are available that will block off the stoma for patients during sporting activities. Specific swimwear is available to facilitate swimming with a stoma.

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 and some special consideration is required for the effect of any medicine on the stoma.³ These include medication:

• For relief of diarrhoea - eg, loperamide, opiates, codeine phosphate.

• For relief of constipation - eg, magnesium hydroxide, ispaghula husk (not for patients with ileostomies, as it increases salt and water loss).