Introduction

End ileostomy

An end ileostomy is created when part of the large intestine (colon) is removed (or simply needs to rest) and the end of the small intestine is brought to the surface of the abdomen to form a stoma. An end ileostomy can be temporary or permanent.

The temporary solution is relevant in situations where the diseased part of the bowel has been removed and the remaining part needs to rest before the ends are joined together. The permanent solution is chosen in situations where it is too risky or not possible to reconnect the two parts of the intestine.

Loop ileostomy

In a loop ileostomy, a loop of the small intestine is lifted above skin level and held in place with a stoma rod. A cut is made on the exposed bowel loop, and the ends are then rolled down and sewn onto the skin. In this way, a loop ileostomy actually consists of two stomas that are joined together.

The loop ileostomy is typically temporary and performed to protect a surgical join in the bowel. If temporary, it will be closed or reversed in a later operation.

Urostomy

If the bladder or urinary system is damaged or diseased and your patient is unable to pass urine normally, there is a need for a urinary diversion. This is called a urostomy, an ileal conduit or a Bricker bladder.

An isolated part of the intestine is brought onto the surface of the right-hand side of the abdomen and the other end is sewn up. The ureters are detached from the bladder and reattached to the isolated section of the intestine. Because this section of the intestine is too small to function as a reservoir, and there is no muscle or valve to control urination, your patient will need a urostomy pouch to collect the urine.

Hyperplasia (Pseudoverrucous Lesions)

Most often seen with urostomies. The wart-like lesions are usually caused by urine pooling on the skin for extended periods of time.

Prevention:

• Correctly cut the barrier to the size of the stoma
• Assess for leakage. Examine ostomy barrier for erosion upon removal and adjust wear time accordingly
• Consider using an extended wear barrier
• If stoma is flush or retracted, consider a pouching system with convexity
• Use a pouch that has a built-in anti-reflux valve to prevent urine from washing over the stoma
• Use a bedside drainage system at night

Management:

• Consult physician or ET Nurse
• Identify the underlying cause
• Modify the pouching system
• Check urine pH to assess urine acidity
• Physician’s orders may include white vinegar soaks and/or a Colly-Seel-type barrier to the wart-like lesions until the condition improves

Fungal Infection (Candida / Yeast)

Candida is a common skin flora that grows in dark, damp sites such as under an ostomy barrier. The rash starts out as pustules before turning into a raised area with erythema consisting of irregular margins with surrounding satellite lesions. Patients may complain of itching or burning. Predisposing factors include antibiotic therapy, diabetes or immunosuppression.

Prevention:

• Use a properly fitting pouching system 
• Eliminate cause of moisture: inspect pouching system for signs of leakage
• After bathing, dry the skin and the pouching system thoroughly
• Assess wear time by examining the barrier for erosion upon removal

Management:

• Consult with physician or ET Nurse
• Identify the underlying cause
• If skin is moist and weepy, consider the crusting technique using antifungal powder in place of ostomy powder (first obtain physician's order / prescription)
• Systemic treatment may be prescribed by the physician if more than one body area is involved
• Blood sugar management may also be considered

Folliculitis

Folliculitis is an inflammation of a hair follicle. It is often caused by bacterial sources such as staphylococcus aureus, streptococci and pseudomonas aeruginosa. Predisposing factors include antibiotic therapy, diabetes and immunosuppression.

Prevention:

• Gently remove the barrier to prevent skin trauma
• Shave hair in the direction of hair growth, but always away from the stoma
• Use an electric razor
• Wash, rinse and completely dry skin before applying a new pouching system

Management:

• Consult with physician or ET Nurse
• Identify the underlying cause
• Avoid shaving hair in affected area - clip hair only
• If skin is moist and weepy, consider the crusting technique using ostomy powder or an antifungal powder (first obtain physician’s order/prescription) if a fungal rash is present
  

Mechanical Injury

Mechanical injury is peristomal skin damage or skin stripping due to pressure, friction and/or shear. Contributing factors include: traumatic removal of the barrier, vigorously scrubbing the peristomal skin and/or a poorly fitting pouching system.

Prevention:

• Gently clean the peristomal skin
• Remove the barrier in the direction of hair growth using the push-pull technique
• Use warm water or adhesive remover to remove the barrier if needed
• Evaluate pouching system to ensure proper fit

Management:

• Consult with physician or ET Nurse
• If skin is moist and weepy, consider the crusting technique

Irritant Contact Dermatitis

Hypersensitivity to chemical agents such as stoma output, soaps and/or adhesives resulting in an inflammatory response. Associated with well-defined erythema, edema or loss of epidermis. Pruritus, crusting, oozing or dryness may be present. 

Prevention:

• Measure and cut opening of barrier to the size of the stoma
• Change barrier on schedule
• Change barrier immediately if burning, irritation or signs of leakage occur
• Examine the barrier for areas of erosion upon removal
• Limit the use of products on the skin

Management:

• Consult with physician or ET Nurse
• Identify the underlying cause
• Use correctly sized barrier and consider using convexity or belt
• Consider using an extended wear barrier
• If skin is moist and weepy, consider using crusting technique

Allergic Irritant Dermatitis

Immunologic response due to exposure to an allergen. Associated with areas of erythema that may correspond to the shape of the contact surface.

Prevention:

• Limit the use of products on the skin
• Add one new product at a time to assess patient’s reaction

Management:

• Consult with physician or ET Nurse
• Remove known or suspected allergen - change type of pouching system and/or eliminate any unnecessary products
• If skin is moist and weepy, consider crusting technique

Pyoderma Gangrenosum

Rare inflammatory skin disorder with unknown etiology seen in patients with inflammatory bowel disease. The lesions are ulcerated with dusky red to purplish margins. Lesions can be painful.

Management:

• Consult with physician or ET Nurse
• Manage the underlying disease and infection per physician order
• Manage ulcer pain per physician’s orders
• Consider steroids with physician’s orders
• Use a flexible barrier with a gentle adhesive
• If skin is moist and weepy, consider crusting technique
• Wound care may be ordered by the physician and is determined by amount of drainage and depth of wound

Prolapse

A prolapse occurs when the bowel telescopes through the stoma, causing the stoma to increase in length. It is most common with loop colostomies. Contributing factors include: abdominal wall opening larger than the bowel, increased abdominal pressure and weak abdominal tone.

Management:

• Consult with physician or ET Nurse
• Instruct patient to avoid weight gain and suggest regular exercise to increase abdominal tone
• Consider the use of prolapse support binder
• Revise pouching system
• Larger pouch to accommodate increased stoma length
• Measure stoma base while stoma is protruding at its largest size (sitting position)
• Cut barrier opening to accommodate stoma at its largest size
• Use a flexible, flat barrier
• Instruct patient to notify physician for signs and symptoms of obstruction and ischemia

Parastomal Hernia

Occurs due to a weakness in the muscle layer of the abdominal wall, allowing intestine to come through the muscle. Contributing factors include a too-large fascial opening around the stoma, poor muscle tone and placement of the stoma outside the rectus muscle.

Management:

• Consult with physician or ET Nurse
• Measure the stoma while patient is sitting up and stoma is at its largest
• Use a one-piece pouching system or a two-piece adhesive coupling system, which allows flexibility and adapts to abdominal contours
• Consider a hernia support belt for added support
• Instruct patient to avoid excessive weight gain 

Mucocutaneous Separation

The sutured junction between the stoma and the skin is called the mucocutaneous junction. When the junction completely or partially separates from the skin, it is called a mucocutaneous separation. Contributing factors include infection, tension on the suture line and delayed healing due to disease processes or corticosteroids.

Management:

• Consult with physician or ET Nurse
• Wound care may be ordered by the physician and is determined by amount of drainage and depth of wound
• Change pouching system as needed to provide wound care

Necrosis

Occurs due to a reduction of blood flow to the stoma affecting stoma viability. Contributing factors include edema of the bowel wall, extensive tension on the mesentery, obesity and too tight or closely placed sutures. Necrosis typically occurs within the first 5 days post-op.

Management:

• Consult with physician or ET Nurse
• Use a transparent, two-piece pouching system for closer inspection of the stoma
• Size the barrier appropriately to prevent constriction
• Resize the barrier as nonviable tissue sloughs and stoma contracts
• Use an ostomy appliance deodorant while necrotic stoma is sloughing off if needed
• Assess for stenosis as area heals