Part 2: Assessment and Management of Stomal Complications: A Framework for Clinical Decision Making
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
Mucocutaneous junction. Stoma Proper complications at the mucocutaneous junction include detachment or separation and stenosis. Mucocutaneous detachment involves separation of the stoma from the peristomal skin. It can be partial or circumferential (see Figure 11) and results from problems with surgical stoma construction, as a secondary complication of retraction or necrosis, as a sequel of poor healing from a disease process, and/or iatrogenically. Problems with stoma construction include creating on oversized opening in the skin when forming the stoma or excessive tension on the suture line.23 In one study, incidence rate of mucocutaneous separation was 3.96%.24
Mucocutaneous separation occurs more commonly in the immunocompromised patient related to the 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. In addition, it may result as an iatrogenic complication from a pouching system that is too tight and causes separation or ulceration at the mucocutaneous junction in the immediate postoperative phase of healing.25
Erythema or induration proximal to the mucocutaneous junction often precedes mucocutaneous separation. The stoma partially or completely separates at the mucocutaneous junction. The clinician gently probes the area of separation to determine the depth (shallow or deep) and circumference. The patient may complain of pain or burning. Assessing the tissue type at the base of the separation often reveals fibrin slough that produces mild to moderate amount of drainage. Stool or urine draining from this site may indicate a fistula.25
The clinician monitors the mucocutaneous suture line postoperatively to determine the extent of the separation, including location and depth. The area of mucocutaneous separation is managed conservatively, focusing on measures to support wound healing.26 Local measures to promote healing include flushing the separated area with normal saline, filling in the dead space with skin barrier paste or strips or absorptive wound dressings in the presence of drainage, and providing a flat pouching system that covers the area of separation, exposing only the stoma. The pouching system needs frequent attention to change the filler material and to assess healing. Healing may require correcting systemic factors (eg, malnutrition) that interfere with wound healing. Stomal complications of stenosis and retraction may result as the mucocutaneous separation heals by secondary intention. If the mucocutaneous separation extends to level below the fascia, surgical intervention may be necessary.
Stenosis. Stenosis, the narrowing of the lumen of the stoma, can occur at either the fascial or the cutaneous level. Extreme narrowing may threaten normal stomal function, impairing the output of the effluent.
Stenosis results from stoma construction techniques, excessive scar formation, prior irradiation to bowel segment, peristomal sepsis, or iatrogenically from trauma resulting from an ill-fitting pouching system. Poor stomal construction can result from inadequate suturing of the fascial layer or inadequate excision of the skin with an insufficient opening through which to bring the stoma. Excessive scar formation results from mucocutaneous separation healing by secondary intention, necrotic stoma, retraction, repeated dilation of stoma, or frequent or continuous peristomal complications.27
Stoma stenosis presents on digital examination as a small lumen at the skin or fascial level. The stenosed stoma may appear normal or the opening may appear small (see Figures 12 and 13). If stenosis is at the skin level, narrowing of the stomal lumen or narrowing of the skin around the stoma may be visible. The patient may have narrow or "ribbon like" stools, pain at the time of stoma emptying, and excessive, explosive, high-pitched gas. The patient with a fecal stoma may complain of constipation followed by a large volume of output. With stenosis at the fascial level, the stoma may be normal in appearance but the patient may present with symptoms of partial obstruction. The patient may have narrow stools, high-pitched gas, or in the urostomy, projectile urinary stream and flank pain.
Stenosis management depends on its level of severity. When stenosis is mild with minimal signs and symptoms, a low residue diet, stool softeners, and adequate hydration may facilitate the movement of soft stool through the bowel lumen. If the patient presents with signs and symptoms of partial stomal obstruction, a digital exam will determine severity. If noted at the fascial level, stenosis often may be managed with gentle dilatation.28 Dilators maybe used or the certified ostomy nurse may perform gentle dilatation. The smallest gloved finger is lubricated and gently inserting into the stoma until the fascial opening is reached. The clinician slides the finger through the fascial opening, holds for 10 seconds without any twisting motion, removes the finger, and repeats the procedure. Gradually, the finger size is increased to achieve an adequate opening. This procedure is repeated for several sessions if indicated. Dilation is considered a controversial management technique because chronic dilations have been reported to cause further stoma stenosis.25 If stenosis is severe, surgical revision is required.
Peri-Intestinal: Parastomal Hernia
Hernia, a protrusion of the bowel or loops of intestine through the fascial opening into the subcutaneous tissue around the stoma, is generally a later complication, occurring months to years after surgery because of surgical technical error or following gradual enlargement of the fascial defect. Most appear within the first two postoperative years.29 After reviewing the literature, it is difficult to determine the incidence rate for parastomal hernia. The rate varies with the type and age of the stoma and with the technique and circumstances of the surgery. Patient characteristics and and postoperative course also could affect hernia development.
A parastomal hernia may occur secondary to problems with stoma construction or related to anomalies of abdominal structure.30 Inadequate surgical closure of the supportive structures around the stoma or creating too large a fascial opening may precede hernia formation. Location of the stoma outside the rectus muscle or in patients with weak abdominal musculature, obesity, or increased intra-abdominal pressure also may precede the hernia. Potential complications related to hernia include mechanical bowel obstruction (intermittent), bowel incarceration, perforation (especially during irrigation), leakage, and peristomal skin dermatitis.31
A hernia presents as a bulge around the stoma in the immediate peristomal area (see Figure 14). It may be partial or circumferential. The bulge may reduce in size in supine position and increase in size in the sitting or standing position. When the patient coughs or bears down during stomal digital examination, the fascial defect presents as an incomplete ring in the area of herniation. Diagnosis is confirmed by a computed tomography (CT) scan with oral contrast. The patient may be asymptomatic or symptomatic with a feeling of discomfort or fullness. It may be difficult to maintain a good pouching seal because the peristomal skin alternately stretches and relaxes with changes in positions. If the stoma incarcerates, the patient presents with an acute obstructed abdomen.25
To help prevent hernia formation, the stoma site should be marked preoperatively within the rectus muscle and patients should be taught to avoid excessive weight gain, to avoid heavy lifting or strenuous activity for 6 to 8 weeks postoperatively, to gradually resume activities including exercises to strengthen abdominal muscles, and to use support binders when prolonged episodes of increased intra-abdominal pressures are expected.
The patient who develops a hernia but is asymptomatic can be managed conservatively. Management includes applying a hernia support belt or binder that offers support for the parastomal hernia, decreases the protrusion, and assists in maintaining a good seal. The patient lies down to help reduce the hernia before applying the belt or binder. The pouching system needs to be modified to accommodate the protruding abdominal surface and to obtain a good seal. The abdominal contour of the patient with a hernia is often round and hard. Pouching modification involves using a one- or two-piece flexible pouching system or a two-piece, flat system with flexible tape border and floating flange. Because the stoma size can enlarge when the hernia protrudes, the stoma should be measured in both lying and sitting positions. The patient who presents with a hernia needs to prevent constipation and ensure soft stools by making the appropriate dietary changes, maintaining adequate hydration, and taking a bulk laxative or stool softener. The clinician should recommend that a patient who uses irrigation as a management system switch to using a pouching system that contains the effluent. When a patient has a parastomal hernia, water may be difficult to instill during irrigation, incomplete evacuations may occur, and it may be difficult to insert the stoma cone. Perforations are less common with use of stoma cone rather than catheter.
The patient should be referred to a surgeon if signs of obstruction, incarceration, perforation, or recurrent pouching difficulties are noted. Surgical options for hernia repair include primary fascial repair, local repair with prosthetic mesh material, or relocation of the stoma. Even after surgical repair, recurrence is common, with a fascial repair recurrence rate of 76%, a stoma relocation recurrence rate of 33%, and a 50% recurrence with local repair using prosthetic material.32
A linear laceration is a cut of the stomal mucosa. Stoma lacerations are the result of poor pouching technique, a system that does not fit properly, and use of a belt. The stoma rubs against part of the pouching system. Prolapsed or peristomal hernias may be contributing factors.33 Lacerations may develop in conjunction with trauma such as a car accident or shaving peristomal skin with a razor. Data as to the incidence of iatrogenic complications such as laceration to the stoma are not available.
Lacerations clinically present as a yellow or white linear discoloration in the stomal mucosa or as an area of denuded deep red discoloration on the stoma that bleeds easily (see Figure 15). Lacerations may be shallow or penetrate the bowel. Because the stomal mucosa has no nerve endings, no pain occurs with injury. Bleeding may or may not be present. The patient may acknowledge an episode of bleeding but does not associate it with stoma trauma. Visual inspection of the stoma confirms the diagnosis.33
Management involves eliminating the causative factor. The pouching system may need to be refitted based on assessment of stoma size and shape. The stoma should not rub against the faceplate or flange of the pouching system. Hemostatic measures are seldom necessary to control bleeding. If necessary, silver nitrate or direct pressure should stop the bleeding. Lacerations usually heal spontaneously.
Pouching System Modifications
Several approaches identified throughout the discussion of stomal complications involve pouching system modification, including the use of convexity, additional support, and adhesive products.
Convexity. Convexity presses into the tissue around the stoma, which increases the degree of stomal protrusion and reduces the risk of undermining of stomal output beneath the pouching system.34 In addition, it allows the faceplate to provide a mirror image of the peristomal skin surface, provides contouring to fill an uneven area in the skin around the stoma, and provides support in the peristomal field. Convexity is available in shallow, medium, or deep levels. A flat pouching system provides shallow convexity by adding paste, washers, rings, or strips to the flat surface that fits around the stoma opening and is used when peristomal skin retraction is 1/8 inch or less. Moderate convexity is provided by using a two-piece system with convex inserts, one- or two-piece systems with built-in convexity, or by ordering a custom moderate convexity faceplate. Moderate convexity is used when peristomal skin retraction is 1/8 to 1/4 inch. Deep convexity is provided by using a one- or two-piece pouching system with built-in convexity; moldable convexity; by adding barrier fills, pastes, washes, rings, strips to the convex faceplate opening that fits around the stoma; or by ordering a custom deep convexity faceplate. Deep convexity is used when peristomal retraction is >1/4 inch.
Support systems. Binders and belts provide additional support when used with convexity. A belt primarily adds support at the 9 o'clock and 3 o'clock positions. If the stoma is not located in the belt plane, the standard belt may tend to "ride up" and compromise the pouch seal. Binders are the better choice, provide circumferential support, and tend to stay in place, especially when the stoma is not located in the belt plane. Binders are available in a variety of widths or can be custom designed to provide an adequate pouch opening and needed support.
Adhesives. A variety of adhesives are available that provide additional support when refitting a pouching system, adding adherence qualities to ostomy faceplates and/or peristomal skin. Products include double-faced adhesive discs, silicone adhesive sprays, liquid skin bond cement, and skin tack (holds belt in place).
Patients who have had surgery that results in a stoma formation face a variety of anxieties and concerns, from learning how to manage their stoma to coping with conflicts over self-esteem and body image. When complications arise, patients' adaptation to stoma surgery becomes even more complex. Surgeons and nurses, especially certified ostomy nurses, need to play a major role in prevention and/or management of peristomal complications. The surgeon who considers a stoma to be necessary as a curative or palliative procedure needs to focus on several aspects of care - providing the patient with emotional support pre- and postoperatively, ensuring that preoperative stoma site selection is provided by either the surgeon or a certified ostomy nurse, and surgically and skillfully providing the technical aspects of the operation. If stomal complications occur, the surgeon must refer the patient to a certified ostomy nurse to facilitate proper assessment and management of the stomal complication. Certified ostomy nurses have the knowledge and skills needed to help the patient make the pouching and lifestyle changes necessary to manage the complication. Certified ostomy nurses need to participate in research studies that identify the best approaches to assessing and managing stomal complications addressed in this article.
A limited amount of research has been done to identify "best practice" in management of stomal complications. Assessment and management are based on training, expert opinion, and successful experiences. Stomal complications and management can be classified according to the location of the complication (eg, stoma proper, peri-intestinal area, mucocutaneous junction) or the etiology of the complication (eg, poor stoma siting and iatrogenic). Stoma complications are most often related to problems with surgical construction of the stoma, stoma location, abdominal structure changes, infectious processes, or iatrogenic factors. Stomal complications affect stoma shape, profile, abdominal contours, and peristomal skin surfaces. They often require modifications in pouching techniques. Whether stomal complications occur immediately or several years postoperatively, a certified ostomy nurse should be consulted to facilitate a plan of care to manage stomal complications and improve the quality of the patient's life. - OWM