STOMA

EXAMINATION OF STOMA

1. Site
a. LIF (Colostomy or Mucus Fistula)
b. RIF (Ileostomy or Urostomy)
c. RH – Proximal Transverse Colostomy
d. LH – Distal Transverse Colostomy

2. Number of Lumens
a. Single Summary of Stoma
b. Double a. Site
b. Number of lumens
3. Spout/Flush – digestive enzyme and highly alkaline c. Spouts
a. Present in ileostomy and urostomy d. Mucosal Lining
b. Absent in colostomy – flush e. Discharge
f. Surrounding skins
4. Mucosa Lining g. Complications
a. Pink and healthy / dusky h. Auscultation
i. Type of stoma
5. Discharge
a. Hard Stool – Colostomy There is a stoma at RIF/LIF, with one/two
b. Soft Stool – Ileostomy lumens, is spout or flush, the mucosa looks
c. Urine – Urostomy healthy, discharging hard/soft stool, overall
surrounding skin shows with or without
6. Surrounding Skin inflammations or excoriations and no signs of
a. Inflammations complications noted such as parastomal
b. Excoriations hernia, prolapse, retraction, ulceration and
etc. on auscultation of the bowel sounds, it is
7. Abdominal Scars present or absent or tinkling sound heard.
a. Midline Laparotomy / APR Scar This is an end/loop ileostomy/colostomy
b. Previous stoma scar possibly from ______ procedure.

8. Complications
a. Haemorrhage
b. Ischaemia, Gangrene
c. Ulcers
d. Separation
e. Prolapse
f. Retraction
g. Stenosed
h. Fistula formation
i. Parastomal Hernia
*complete examination with DRE, psychosexual hx, I/O chart to exclude high output stoma
Indication for Stoma
- Feeding - gastrotomy/jejunostomy
- Lavage – appendicostomy
- Decompression – bypass obstructing bowel lesion
- Diversion – protect distal anastomosis (contaminated peritoneal cavity, ileorectal
anastomosis, cystectomy)
- Exteriorization – perforated or contaminated bowel, AP resection

Complications of Stoma
- Stomal Diarrhoea (water and electrolyte imbalances, hypokalaemia)
- Nutritional Disorders (B12 Deficiency – Megaloblastic anaemia)
- Cholelithiasis (disruption of enterohepatic circulation, bile salts, cholesterol,
phospholipase) & Nephrolithiasis (acidic urine, dehydration)
- Psychosexual
- Crohn’s and Parastomal Fistula
- Skin erosion leads to dermatitis (high alkaline and enzymes)

Possible Procedure
- End Ileostomy – Pan proctocolectomy in FAP, HNPCC
- Loop ileostomy – LAR, ULAR, Ileorectal anastomosis
- End Colostomy with perineal scar – APR
- End Colostomy with patent anus – Hartmann’s Procedure (infection, decrease
perfusion, unstable condition)
- Loop Colostomy – irresectable locally advanced tumour, time to shrink tumour
with chemo and radiotherapy, prevent future intestinal obstruction, bed ridden
patient, Fournier gangrene, perineal disorder

Factors Affecting Anastomosis Healing

- Tension of suture line (surgical techniques)
- Vascularity
- Presence of serosa lining
- Mucosal inversion

After Colectomy Procedure

- Primary Anastomosis
- Double barrelled stoma
- Mucous fistula with stoma (with sufficient length)
- Hartmann’s Procedure

Hartmann’s Procedure
- Perforation of bowel leads to gross peritonitis
- Unstable patient after resection
- Perforated tumour
- High tension leads to
Ileostomy Management
- Replace loss fluid with Hartmann’s or Ringer’s Lactate
- Application of base plate
- Cream

High Output Stoma (Jejunostomy)

- Producing effluent volume >1000ml/day
- Clinically significant when effluent volume >2000ml/day (cause water, Na & Mg
depletion)
- Primary cause – loss of normal daily secretions produced (1.5L saliva, 2-3L gastric
juice, 1.5L pancreaticobiliary) in response to food and drink
- Other causes – intraabdominal sepsis, infective enteritis, partial/intermittent
bowel obstruction, recurrent disease, sudden stopping of drugs, prokinetic drugs
(metoclopramide)
- Complication – Hypokalaemia pathophysiology
a. Sodium depletion leading to secondary hyperaldosteronism
b. Hypomagnesaemia leading to increase renal potassium excretion

Management of High Output Stoma

- Exclude potential causes – rule out intraabdominal sepsis, intermittent bowel
obstruction, prokinetic drugs, steroids withdrawal, enteric infection, Clostridium
difficile infection
- Reduce fluid and electrolyte losses
a. Restrict to 500ml/day and IV Saline
b. Loperamide 4mg QDS
c. Monitor I/O chart, daily weight, serum electrolyte and Mg level
d. Screen for under nutrition (BMI, Weight loss) and refer to dietician
- Ongoing HOS – optimise with anti-diarrhoeal medication
a. Continue fluid restriction, if effluent >3000ml/day consider NBM for 24
hours to assess gastrointestinal secretion
b. Commence St. Marks or WHO glucose-electrolyte replacement solution
1000ml daily, random urine sodium (aim >20mmol/L)
c. Increase Loperamide to 8mg QDS
d. Starts on Omeprazole 40mg OD-BD to reduce gastric secretions
e. Strict monitoring (I/O chart, twice weekly weight, weekly Mg level)
f. Starts on IV Magnesium sulphate and T. Magnesium Oxide if serum
magnesium <0.5mmol/L
- Evaluate efficacy if HOS continues
a. Refer to nutrition support team
b. Add codeine phosphate 15mg-60mg QDS before meals
c. Increase loperamide dose to 10-12mg QDS
d. Effluent >2000ml daily after 2 weeks, Octreotide 200mcg TDS for 3-5
days can be trialled
e. Review compliance to oral fluids and increase St. Marks/WHO solution
if required