Ostomy

Complex GI
Nursing 246

Ostomy For The Purpose of Fecal Diversion

Indications
• Inflammatory Bowel Disease
–Primarily Ulcerative Colitis
• Perforating Diverticulitis
• Cancers, Tumors
–Colon or Rectum
–Pelvis
–Rectovaginal Fistula
• Trauma
• Birth Defects

1
 Location of Ostomy
Gives you a clue re: etiology as well
as what exactly was removed
• Ascending colon:
– _____________
– _____________
• Transverse Colon
– ______________
– ______________
– ______________
• Sigmoid……………….

MOST OFTEN….
• sigmoid colostomy

• The stool from a colostomy is usually firmer

than that from an ileostomy

http://www.youtube.com/watch
?v=QwpG4I2JM4U
Sigmoid Colostomy

2
 Reasons for this
procedure:
1.
2.
3.
4.

QUESTION?
• Does the patient always require
the creation of an ostomy if a
section of the bowel has been
removed?

NO The surgeon can remove a part

of the colon and re-connect without
creating an Ostomy

3
 This is called a Primary END to
END Anastomosis

IF Hartman’s Pouch
• only one stoma
• The non-functional end of the bowel
stitched or stapled shut and left inside
• Plan is usually to reconnect
• Seen with:
– _______________
– _________________

4
 The surgeon might also construct
an END sigmoid colostomy with
a “Mucous Fistula”

There is no stapling of the

lower section so it will drain
Mucous.

Since that section is not

connected to the upper
bowel it cannot drain
feces

Double-Barrel Ostomy
• the surgeon cuts out a section of diseased
colon
• there are two stomas
– One discharges effluent
– The second = mucus fistula= secretes
mucous

5
 Loop Ostomy
• The most common form of temporary
ostomy
• most often performed for creation of a
temporary stoma to divert stool away from
an area of intestine that has been blocked
or ruptured

ROD

Rod usually removed 4-6 days post-op

6
 Loop Ostomy (cont)
• This rod is removed a few days later when
the wound has healed enough to stop it
slipping back.
• The loop of bowel that is exposed is then
cut partway open (but not completely
severed) during surgery.
• The result is two openings very close
together.

The loop ileostomy will have two openings - the top opening
called the proximal opening where stool is passed and the
distal opening or bottom opening that is connected to the
resting portion of bowel

7
 ILEOSTOMY

The outline of the rest

of the colon In this illustration
indicates the colon was removed

Ileostomy
• Ileostomy - usually located in RLQ
• Usually entire colon removed
• liquid to pasty stool (effluent)
• highly irritating to skin due to high levels of
caustic, proteolytic enzymes
• Uncontrollable at first
• never irrigated for X-ray
• never use laxatives

8
 Post-Op Care of Ileostomy
• Greatest emotional challenge: acceptance of
change in body image
• Greatest physical challenge:
– keep output < 1500 ml daily
• Urine output is generally less
– Intake must compensate for this to protect the
kidneys

Patient Education: Ileostomy

• Do not fast
• Avoid dehydration
– Monitor urine output
– Drink at least 2 quarts of fluid daily
• Medications:
– Coated and timed release will NOT be absorbed
so avoid those
– There have been no reported problems with the
absorption of the birth control pill
– Consult pharmacist with any medication
prescribed

Sodium and the Ileostomate

• Salt output from an ileostomy is high
• Do not eliminate Na+ from the diet (even if
you have HTN)
– How would body compensate for this?
• __________________________
• __________________________
• But do not increase the amount of Na+ either
– Avoid too much salt because it increases ileal
output.

9
 Diuretics

• Should be used with great care

• salt imbalance and dehydration can result
from additional fluid loss.

Laxatives
& Ileostomates
• A person cannot become constipated with
an ileostomy.
• Laxatives, enemas, rectal tubes or rectal
thermometers should not be used.
• If a person were not passing stool or
flatus, the concern would be a blockage.

Rectal Cancer
• Local Excision

10
Abdomino-Perineal Resection
• required if the cancer is very low in the rectum,
near or involving the anus (within 5 cm)
• Two surgical incisions
– the distal sigmoid, rectum and anus, along with the
sphincter muscles, are removed via a perineal
incision
– Stoma created via abdominal incision.
• This type of surgery for rectal cancer requires a
permanent ostomy (colostomy).

11
 Post Op Care of the AP
Resection
• There are 2 incisions + a Stoma is created
– Abdominal incision
– Perineal incision
• Perineal incision wound management
– Packing?
– Partial closure with penrose drains?
– Primary closure with closed-suction drainage?
• Meticulous post-op care is required

Low Anterior Resection

• removing the cancer, a larger area of
healthy tissue around it, and the
surrounding lymph nodes
• The cancer is far enough away from the
anus
• Is a “sphincter saving” procedurere
• Remaining ends of the colon and rectum
are then sutured or stapled together
(anastomosis).

12
 Proctectomy
• the entire rectum is removed down to the
level of the anal canal
• the remaining ends of the colon are
sutured or stapled to the anal canal.
• may require that you have a temporary
ostomy

Total Proctocolectomy

• aka “Brooke Ileostomy”

– Entire colon, rectum and anal sphincter
removed
– Considered permanent
• OR -The colon only may be removed with
rectum and anal sphincter left intact with
the plan to have a “J” Pouch constructed
(aka ileal pouch and anal anastomosis –
see Reconstruction slides)

13
 Reconstruction

Continent Stoma (Kock Pouch)

And
Ileoanal Pouch Anastomosis

Kock Pouch
an internal pouch constructed from the ileum
to store waste products

a thin tube is inserted

into the stoma to
drain the contents
a few times
a day

Rectal Reservoir
Returns to the most “Normal” function
Patient must understand the pouch
(rectal reservoir) takes time to adapt and
perform

IAAP: Ileal Pouch Anal Anastomosis

14
 Permanent or Temporary??
• Both colostomies and ileostomies can
either be permanent or temporary.
• How do you know???????????
• If temporary when are the ends re-
connected or the connection made to the
“J” Pouch …????
– The “TAKEDOWN”
• Generally 3-6 months after Ostomy
construction;
• or 3 months to connect to “J” Pouch

The stoma and peristomal skin.

The stoma is above skin level and is a healthy red color.

Ileostomy

With appliance in place

15
 More on The Stoma
• Has no nerve endings so will not be painful to
the touch.
• Will always have some degree of movement
(peristalsis), particularly while functioning for
stool.
• Initially swollen after surgery
• Will decrease in size over six weeks
• No sphincter = no voluntary control over stool
• External appliance worn to collect the stool.

Stoma Maturation
• The stoma looks swollen within 4 to 6
hours
• Swelling progresses for the first 2
days
• By the 5th day subsides markedly
• Edema continues to decrease for 6 to
8 weeks
• While edematous, the stomal mucosa
is paler, translucent and soft

Pouching Tips
• During this edematous phase, sizing the
opening of the faceplate is important
– prevents stomal constriction and ischemia.
• Stoma measurement selected for the
pouching system should allow for an
opening 1/8th inch larger than the stoma
size
– prevents constriction that could impair
stoma blood flow.

16
 How Long Before Fully
Mature?
• _________Months
• Thus
– Measure and resize barrier opening at each
pouch change

Potential Problems with

Stomas
Site, Skin, others

Main Issue with Poor Siting

Leakage and resultant peristomal irritant contact dermatitis

Poor stoma siting – at level of umbilicus

and within a skin fold

17
Poor stoma siting at the inferior end of an incision

Problems with the Stoma Itself

Eg. Post-operative stoma edema may be

a factor in the development of
Necrosis

a dark red may indicate bruising, or ischemia

(especially immediate post-op)

18
 Not Ischemia – Why NOT??

Retraction imminent:
the bowel is looped over the rod under tension.

19
 String coming out
of the distal stoma
was passed through
a distal stricture and
out of the anus

Appearance of violaceous rash commonly due to

Candida albicans..

Post-Operative Stomal Bleeding

Mucocutaneous separation

Usually immunocompromised patient (malnutrition,

corticosteroid therapy, or diabetes) that results in
superficial infection and poor healing. It may result
secondary to disease processes such as infection or
post-radiation therapy.

20