most often in the immediate postoperative period. It is usually due to venous congestion or arterial insufficiency. If the necrosis involves only the superficial few millimeters of the stoma, then observation will usually be successful; however, if it extends deep to the fascial planes, then an urgent revision is warranted. The ED physician can determine the extent of necrosis by inserting a lubricated test tube in the stoma and with a flashlight or using a lighted anoscope.
Major bleeding from the stoma is uncommon. Minor bleeding can be from the initial surgery or over from vigorous stomal cleansing. Pressure, handheld cautery, or silver nitrate is usually sufficient to manage minor bleeding episodes. Topical hemostatic agents are sometimes helpful adjuncts. Finally, a well‐placed figure‐of‐eight stitch of monofilament suture on a noncutting needle can stop bleeding from an isolated bleeding vessel on the surface of the stoma, which is insensate.
Stomal retraction is defined as any stoma that is 0.5 cm or more below the skin surface, is noticed within six weeks of stoma formation, and requires surgical intervention. It can occur from excessive tension on the bowel and occurs more often with ileostomies and in obese patients. Stomal retraction can cause leakage, difficulty with pouch adherence, and skin irritation. Supportive care includes using a convex pouching system and belt and binder; however, many require revision.
Late Stomal Complications
Parastomal hernias are more common with colostomies and have a reported incidence of up to 48%. Other risk factors include obesity, poor abdominal muscle tone, chronic cough, and placement of the stoma outside the rectus muscle. Parasternal hernias are usually asymptomatic, but, as the size increases, it can impede adherence of the ostomy pouch. Strangulation and obstruction are rare but serious complications, and it is important for the ED physician to be comfortable determining if a hernia is incarcerated. Any hernia that cannot be manually reduced, is extremely painful, or appears dusky requires urgent surgical consultation. Symptoms of obstruction, including vomiting, abdominal distention, and decreased ostomy output, require two‐view abdominal x‐rays. Elective surgical revision is performed for definitive management of parastomal hernias; however, there is a high recurrence rate. Nonoperative management includes abdominal support belts and education regarding avoidance of heavy lifting or other maneuvers that may increase intra‐abdominal pressure.
Figure 2.1 Stomal prolapse.
(Source: Photos courtesy Judith Stellar)
Stomal prolapse occurs when a proximal segment of the bowel intussuscepts and protrudes through the stoma (Figure 2.1). The incidence of prolapse is 7–26% and is more common with loop transverse colostomy and end descending colostomies. The majority of prolapses are not of clinical significance but can be distressing to patients and make appliance placement difficult. Small, uncomplicated prolapses can be manually reduced by the ED physician at the bedside. Sedation may be necessary depending on the size of the prolapse and the discomfort of the patient. Before reduction is attempted, the edema of the prolapse may be reduced by applying cool compresses or osmotic agents such as honey or sugar for approximately 30 minutes. The prolapse is then lubricated with a water‐soluble lubricant, and with gloved hands, circumferential pressure is applied on the prolapsed mucosa. Placing a finger in the center of the prolapse may help guide the reversal process. After the prolapse is reduced, an abdominal binder should be placed, and the patient should be instructed to avoid lifting or other activities that increase intra‐abdominal pressure and should follow up with their ostomy team as an outpatient. Complicated prolapses, prolapses causing ischemic changes or severe mucosal irritation and bleeding, and those that are unable to be reduced by the ED physician usually require surgery.
Stomal stenosis is a less common complication of ostomies with an incidence of 2–15% and more often seen in patients with Crohn's disease. Symptoms of stomal stenosis include noisy stoma when flatus is passed, reduced output, diarrhea, or cramping abdominal pain followed by explosive output. Severe stenosis may present with obstruction. The ED physician may assess for mild stenosis by digital exam or attempting to pass a catheter.
Figure 2.2 Irritant dermatitis.
(Source: Photo courtesy of Judith Stellar)
Cutaneous Complications
Dermatitis is common among patients with GI diversions and usually caused by the chronic effect of the proteolytic enzymes and high alkaline content of the stool and other drainage on the peristomal skin. The degree of irritation can range from mild dermatitis to severely denuded skin along the inferior aspect of the stoma (Figure 2.2). Fungal infections due to Candida albicans frequently accompany the dermatitis since the warm moist environment makes an ideal location for fungal infections. In these cases, the skin is often raised and erythematous with well‐circumscribed papules or satellite lesions. Application of clotrimazole or miconazole nitrate 2% powder is often sufficient for treating candidal infections. Mixing an antifungal powder with a small amount of water and then painting it onto the skin can enhance the adherence of the pouch. Contact dermatitis due to an allergic reaction from the stoma products or tape can also present with mild to severe skin breakdown; however, the hallmark of allergic dermatitis is the precise outline of the rash that matches the stoma product. Avoidance of the appliance and application of topical steroid cream and oral antihistamines are often helpful. Cellulitis can occur in the setting of severe excoriations and may require systemic antibiotics. The rash associated with cellulitis is usually more tender, warm, and indurated than in typical forms of irritant or allergic dermatitis.
Metabolic Derangements
Patients with ileostomies are at higher risk for metabolic derangements due to the larger volume of effluent that is produced daily. The normal adult output is 500–1300 ml/day, which may be increased in the setting of obstruction, infectious enteritis, bacterial overgrowth, and dietary indiscretion such as diets high in sugar, salt, and fat. High stoma output can lead to hyponatremia, hypokalemia, and hypomagnesaemia. If more than 60–100 cm of the terminal ileum is resected, malabsorption of fat and vitamin B12 can occur. The initial evaluation for high stoma output includes obtaining a set of electrolytes such as magnesium and phosphorous; a complete blood count to assess for anemia; a two‐view abdominal x‐ray; stool studies for Clostridium difficile, ova and parasite and bacterial culture; and obtaining a detailed diet history. Management of high stoma output includes identifying and treating the underlying cause. Patients with Crohn's disease may present with increased output as a sign of an acute flare, and gastroenterology consultation should be obtained for these patients. If the electrolytes are normal, and the patient is well hydrated and hemodynamically stable with a benign abdominal exam, the patient may be discharged home with instructions to increase their fiber intake and decrease their intake of sugar, salt, and fat. For patients with metabolic derangements, dehydration, or other concerns, intravenous fluids, electrolyte replacement, and bowel rest are the initial steps. Once the patient is stabilized, long‐term management of high stoma output may include antidiarrheal agents including loperamide, oral fluid restriction, dietary salt supplementation, H2 antagonists, and proton pump inhibitors. Patients with ileostomies are also predisposed to kidney stone formation due to their state of chronic mild dehydration and acidic urine.
Consultation
ED physicians can manage many of the complications from GI diversions such as small