Part 2: Assessment and Management of Stomal Complications: A Framework for Clinical Decision Making
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Continued from Part 1
Bleeding. Bleeding, either superficial bleeding that does not stop spontaneously or excessive bleeding from the stoma usually at the mucocutaneous junction, must be differentiated from the occasional bleeding a patient experiences from the stomal mucosa that can be caused by mild trauma during an pouching system change. Bleeding as a stoma complication can result from inadequate hemostasis during stoma construction, portal hypertension, trauma, underlying disease, and because of some medications, such as prolonged use of analgesic anti-inflammatory drugs,10 blood thinners, and chemotherapy. No data exist as to the incidence of bleeding as a stomal complication.
Inadequate hemostasis during stoma construction results in bleeding within the first 48 hours following surgery. It can present as oozing or frank bleeding (see Figure 9). Oozing is usually venous or capillary in origin. When the pouching system is removed, oozing appears as a slow forming pool in one of the quadrants of the stoma. It usually comes from the edge of the gut. Treatment is conservative. Superficial bleeding that does not stop spontaneously requires cauterization, suture placement, topical hemostatic agents (silver nitrate), or direct pressure. Frank bleeding presents as blood that runs down the abdominal wall and usually comes from a "pumping" mesenteric artery deep to the mucocutaneous junction. Frank bleeding requires immediate notification of the surgeon. The surgeon removes sutures, lifts the mucosa, secures the vessel with fine forceps, and ligates the bleeder.1
Luminal bleeding (bleeding that comes from the lumen of the stoma) is often associated with underlying disease. Bleeding from an ileostomy may be a sign of recurrent Crohn's disease; bleeding from an ileal conduit may relate to the deposits of crystals or inflammation secondary to infection with alkaline urine or from missed polyps. The clinician should always notify the surgeon regarding luminal bleeding.10
Bleeding also results from portal hypertension. In a patient with cirrhosis of the liver, scarring within the liver obstructs venous outflow from the intestine, leading to dilated veins in the gastrointestinal tract. Varices occur around the stoma. The patient presents with caput medusa - bluish-purple discoloration of skin caused by dilation of the cutaneous veins around the stoma (peristomal varices) (see Figure 10).18,19 The area blanches when pressed and displays irregular, small blood vessels. Portal hypertension results in bleeding from the mucocutaneous junction. If severe, it may require sclerotherapy or portosystemic shunting.
The stoma also may bleed secondary to pharmacological therapy. The most common cause of pharmacological bleeding is the adverse effect of prolonged use of analgesic anti-inflammatory drugs. Bleeding is due primarily to the inhibition of platelet aggregation induced by salicylates, indomethacin, and other like drugs. Diagnosis is confirmed by coagulation studies.
The clinician assesses the amount, severity, and source (stomal, mucocutaneous junction, or bowel) of the bleeding. Patient history should include questioning regarding medications, especially over-the-counter medications. If trauma caused the bleeding, the traumatic event should be eliminated. Minor bleeding from stomal surfaces usually resolves spontaneously. Superficial bleeding that does not stop requires cauterization, sutures, hemostatic agents, or direct pressure. Massive or repetitive bleeding requires surgical interventions.20-22
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