10. Management of Patient with Colostomy - Care Based on Surgical Construction and Location

In this class, we're going to discuss management of a patient with a colostomy. We're going to focus specifically on implications for care based on surgical construction and anatomical location. We're going to talk about implications for surgical construction and on care of the patient with a colostomy. Same thing with anatomical location, and we're going to define a lot of terms, mucus fissula being one of the Hartman's pouch being another. Okay, so we know that there are many ways in which a colostomy can be constructed, and we also know that surgical construction has implications for care management. Anatomic location of the stoma also has implications for care management because it has a major impact on volume and consistency of the stoma. So we are going to talk about how does care for an end stoma differ from care for a loop stoma. An end stoma has a single lumen opening versus a loop stoma, which is you see from the illustration in the middle, as both a proximal opening, essentially a mouth to stoma, and a distal opening, stoma to anus. So a lot of differences in surgical construction of a stoma and things we have to think about when we're taking care of the patient with the colostomy and teaching the patient with the colostomy. So we'll start with an end stoma where the distal bowel has been removed. So if you look at the illustration on the bottom right, you will see that the stoma, the colostomy, is now the end of the bowel. This procedure is known as an abdominal perineal resection, where there's both an abdominal incision and a perineal incision, where the sigmoid, the rectum, the anal canal, and this fainters have all been removed. Any time you have an APR, you know that the colostomy is permanent because there's nothing that remains distally. You can't do a reconnection, there's nothing to connect to. Also we have to consider care of the perineal wound. Now most of the time they close the perineal wound with sutures. They will frequently use some kind of suction or drain system to evacuate fluid and to promote healing. When patients ask what's it going to look like down there, I mean is there still going to be a hole, no hole, no opening, just a suture line? Now very occasionally when they remove the rectum, if there are issues with bleeding, if there are issues with infection, they'll decide to let that wound heal from the inside out and they'll use packing, but the vast majority of patients are going to have sutures and a closed incision. Another option is to have an end stoma with closure of the distal bowel. So this is that Hartman's pouch or Hartman's procedure. What they do here is they remove the damaged or diseased section of bowel. They bring the proximal end out as a stoma and end stoma with a single lumen. The distal end of the bowel is sewn closed, they use the term over sewn so it can be closed with the suture line, close with the staple line and left in place. The intent always is for this to be a temporary diversion. The goal is to come back once all inflammation is resolved and connect the proximal to the distal bowel. Now a common question from patients is well what happens to that section? What happens to the rectum? It's just sitting there. Is it going to be okay? Is it going to die? Is it going to shrivel up? So you want to explain to them that blood supply remains intact, I tried many different analogies to try to explain this to patients and the one that seems to make the most sense to them. I tell them it's very much like the uterus of a non-pregnant woman. It's just sitting there waiting for business, it's kind of on vacation. If it gets business, it'll get up and go to work and until then is literally hanging out. Still talking about Hartman's pouch, Hartman's procedure. Now remember that they go in because there was an acute issue, almost always this procedure is done following bowel perforation or an acute inflammatory process. So the patient has not undergone a bowel prep at the time of surgery and typically there is some stool in this distal segment of bowel that's being left in place. Now most of the time when peristosis resumes and they start having output through the stoma, most of the time they'll evacuate that little bit of stool through the rectum. If not, you might need to recommend a suppository or a small enema to cleanse that distal segment, especially if the patient's complaining of any discomfort. You also want to explain to the patient that that distal segment will continue to produce mucus and that they might occasionally feel the urge to go and if they do feel that they should go to the bathroom, see what passes and if they see dark mucus they should know that's normal because those mucus decreeing glands are still active. So you just want to explain that to the patient. I've had people like, "I think something's wrong, I know everything's supposed to come out this ostomy but it's still coming out my bottom, is that okay?" Also, the patient who's undergone a Hartman's pouch procedure is at some risk for diversion colitis, especially if a reversal is delayed or is not possible. Well what is diversion colitis? So look at that little segment, look at the illustration on bottom and you see that segment that is just sitting there. It's isolated from the rest of the bowel. Now remember that the colon contains a lot of bacteria, many of which are very important to health, like lactobacillus, bifidobacterium, saccharomyces. Also remember how those good bacteria are maintained. It's through interaction between the bacteria within the colon and fiber in the diet. And so normally that interaction maintains healthy bacterial balance, maintains all of those protective molecules. But now you've got this little section that's totally separated from the rest of the colon. And have access to any of the other bacteria doesn't have access to fiber taken in through the diet. So no longer has the ability to produce those protective compounds. And as a result, this segment can become inflamed because of alterations in bacterial balance. You can get overgrowth of pathogens that are not held in check by the good bacteria. How would you know? Well, the patient developed symptoms. They start producing a lot of mucus. So they might have frequent urge to pass mucus rectally. They might notice some bleeding. They might tell you they just don't feel good. They're running fever. How do you treat that? Well, the first thing we typically do is we'll just do like a suppository or a low volume in them, just to kind of cleanse that distal segment. Get that old retained mucus out, get some of those overgrown bacteria out. Many times they'll treat with anaerobic antibiotics like flageal or cipro. If symptoms continue, they might use anti-inflammatory medications like they do for inflammatory bowel disease. And if symptoms still persist, they're going to look at the patient to determine can we do a reversal? Can we reconnect the bowel and restore normal bowel function, normal bowel health? So diversion colitis is not common, but possible. And as an ostomy nurse, you need to know about it. A very uncommon approach to colostomy construction is to form an end stoma with a mucous phishalum. This is occasionally known as a double barrel, which is a terrible terminology and very rarely used. You don't want to use that. You want to use the term colostomy with mucous phishalum. Now what happens here, they take out the diseased or damaged section of bowel. They bring the proximal bowel out as a functional stoma of colostomy. That's where the stool comes out. And then they bring the distal bowel out as the mucous phishalum. The intent, most of the time, is for this to be a temporary diversion. Both ends of the bowel remain intact, the fincters remain intact, rectum remains intact. So hopefully this will be a short term diversion, a temporary diversion, and reconnection will be done. And again, proximal drain stool, distal drains mucous. Most of the time it's pretty clear, which is proximal, which is distal, but sometimes it's not clear. So if you look at the illustration in the middle, the patient slide, the proximal stoma is on the patient's right, the distal stoma of the mucous phishal is on the patient's left. Sometimes again, you know exactly which is which. Sometimes you're not sure until bowel function resumes. And then as I always tell staff, the proximal is the one that poops. OK, so what about management? Well obviously you have to pouch the proximal stoma because that's where the stool is coming from. So if you look at the illustration on bottom, the proximal stoma is the one on top. If you look at the illustration on top, the proximal stoma is the one on top, distal stoma is the one on bottom. If you look at the one in the middle, the proximal stoma is on the right, and distal is on the left. If you're unsure initially, which one is proximal, pouch both of them until you know for sure. In general, you remember PPDD, pouch the proximal, dress the distal. The distal is only going to make mucous, you don't usually need a pouch for that. If the stomas are very close together, so we see this a lot in the pediatric population where they frequently do bring out both ends of the bowel, and they frequently bring them outside by side, and almost looks like a figure eight, then you're going to have to pouch both of them in one pouching system. And the other time that you'll need to pouch, the distal is if it's draining a large amount of mucous, or occasionally if you had a patient who was obstructed, you'll get reverse peristalsis, and you'll actually have fecal drainage through the distal stoma initially. So if in doubt, pouch both, if side by side, pouch both, and if you're having a lot of drainage from the distal pouch both. Again, you have some potential for diversion collides because look at the illustration on bottom. Once again, you have that segment of bowel that's isolated from the rest of the bowel. No longer has access to fiber intake, so it's pretty easy to get a bacterial imbalance that can become symptomatic. And now a loop clostomy. So here you have a totally different approach. With end stomas, the bowel is always divided, and you're dealing with this end of the bowel, this end of the bowel. But with a loop clostomy, the bowel is not divided. Instead they make a little incision into the abdominal wall. Look at the middle illustration. You see where they bring out the entire loop of bowel is brought out through that incision. They're going to stabilize the bowel at the abdominal surface with either a plastic rod or a catheter, why? Because if they don't, that loop of bowel is going to retract back into the abdominal cavity. It doesn't want to be out here where it's cold and dry and bright wants to be inside, where it's dark and warm and wet and friendly in its usual environment. So you will almost always see some kind of support device at the abdominal surface. And then as you can see in that middle illustration you can see that the anterior wall of the bowel has been opened. Now again you have the potential for reversal and the intent is that this will be a temporary diversion because the distal bowel remains intact, sphinctures remain intact. So here again you can see that the anterior wall of the bowel has been opened. This permits a fecal diversion. The posterior wall of the bowel remains intact. When they turn the anterior wall of the bowel back on itself and mature the stoma, as you see in the illustration on bottom, you end up with one stoma. So if I was looking to pouch this I would just need one pouch because I have one stoma, but I have two distinct openings. So I have a proximal opening and I have a distal opening. That occurs because remember that the colon wall has elasticity. It has those elastic bands, the tiniacoli, and when you open the anterior wall the natural elasticity causes the posterior wall to push forward and that creates that separation between proximal and distal. Now the fact that you have both a proximal opening and a distal opening can be advantageous because it means you have access to the proximal bowel and access to the distal bowel. So if you need to instill fluid or medication, proximally you can do that. If you need to flush the distal bowel you can do that. Almost always when they do a loop clostomy they surgically mature the stoma. So we have said in previous classes surgical maturation means the bowel is opened. The bowel is turned back on itself very much like a turtleneck. Turn it back on itself and suture it to the surrounding skin so that it's the mucosal layer, the inner layer of the colon that is exposed. So that's what you see in the two middle illustrations. You see that the anterior wall has been turned back on itself, sutured in place. You see that the entire stoma is bright red and moist because the mucosal layer is exposed. Very occasionally they are unable to turn the bowel back on itself and sutured in place typically because the bowel is extremely edemotus and in that case you'll get self maturation. So if you look at the illustration on bottom you see the mucosal layer exposed at the top and then you see the serosal layer exposed distally or proximally actually. So the distal portion shows mucosa, proximal portion shows serosa. When the serosa exists, it's supposed to air, it becomes sticky. That causes the bowel wall to literally stick to itself, adhere to itself, and to start to roll down on itself. So gradually that stoma will self mature, it will take several weeks. And they don't like to permit that because when you get self maturation the inflammation associated with that can cause a partial obstruction. So standard of care at this point in time is open the anterior wall, turn the bowel back on itself, suture it to the dermis so that you have exposure of the mucosal layer. You may never ever see a stoma that self matures. But as an ostomy nurse you need to know that it's a possibility, you need to know what it involves and you need to know that should that process be occurring you'll see exposed mucosa in the center of the stoma and you'll see yellow and flame serosa all the way around the edge. So let's talk a little bit more about that support device. Patients ask a lot about that. What's that? Therefore, how long is it going to be there? How do I work around it? What's going to happen when they take it out? Is it going to hurt? So before you say what the purpose is, hold the bowel in place at the abdominal surface until healing is complete until it has granulated to the abdominal wall and it's going to stay there. This slide shows you the most commonly used support devices. So on the top you see the Hollister bridge. It's a butterfly bridge. In the middle you see just a red rubber catheter that's fed through the mesenteri and then sutured to it self usually. That's very commonly used. On the bottom you see another type of plastic bridge support. This is called a T bridge support and one end of the bridge, one end of the T will literally flip back on itself to facilitate removal. How long does it stay there? Usually 5 to 14 days. So many surgeons will remove the support when the patient comes back to clinic for their first post-op visit. Remember that the determining factor is has the stoma granulated to the abdominal wall. So I can literally push the stoma a little bit and I can see. Is it adherent to the abdominal wall at that mucocutaneous junction? Or do I still have an open wound all the way around the stoma? If I still have an open wound I should not remove the support. If it's now adherent to the abdominal wall and that open wound has granulated in, yes, it's safe to remove the support. Many times the surgeon will delegate support removal to the ostomy nurse. If they have, then you're going to verify that the bowel has granulated to the abdominal wall. It's safe to remove the support. The specific procedure will be dictated by what kind of support you have. If you have the bridge, the butterfly bridge, like you see on the top, many times they'll have little sutures and you have to clip the sutures, then you fold the bridge against the abdominal wall till it becomes a semi-circle and it just slides right out. If it's the red rubber catheter, you can just cut it and it slides out. If it's the tea bar, you flip the tea and it slides right out. So you're removing the sutures and then you just slide the support out. If you have any questions about the specific support you're going to clarify with the surgeon, how that support is removed. What about pouching? Patients are very concerned about this and this is actually a big challenge because many times we're teaching the patient to change his or her own pouch and they still have the support device in place. So you have to decide are you going to pouch on top of the support or are you going to pouch around the support? If it's sutured in place, you have to pouch on top or you have to cut the opening wide enough to encompass the support. If it's a red rubber catheter, you can pinch it up and you can tuck it into the pouch and you can pouch around it. When you're pouching on top of a support device, you need a very flexible pouch, most of the time. Many times if there are sutures, it's helpful to take steery strips or paper tape and put the steery strips or the paper tape on top of the sutures to protect the sutures from the hydrocholoid barrier and from paste. Still talking about loop colostomy, again you will have significant distal bowel almost always. Many times loop colostomies are done in the transverse colon. Things are done in the descending. So you will definitely have functional distal bowel. In the majority of patients, once peristals is resumed, then the distal bowel will empty itself. So I was talking to a patient just a couple of weeks ago and I was telling him, showing him a diagram very much like this and explaining to him, you probably still have stool over here in this section of the bowel. So you might still feel the urge to go and you might pass stool through your rectum. And he's like, oh thank goodness, that's what happened last night and I was so worried I couldn't figure out why that was happening. So you want to explain to patients that this is normal. If they do not pass stool spontaneously within a few days and they're passing stool into the pouch, then you may need to get an order for a suppository for a small enema to flush out the distal bowel or you could also flush some tap water through the distal opening of the stomach. And again, you're going to tell the patient periodically, you're probably going to feel the urge to go, that's normal. The mucus will probably look really dark, that's normal too. And once again, the potential for diversion colitis, if we're unable to close the ostomy within a timely period, a relatively short period of time. So usually we can reverse the ostomy within three to six months. So we don't typically see diversion colitis within that timeframe. But if for some reason ostomy reversal is delayed or is not possible, the longer they have that loop ostomy, the more likely they are to develop diversion colitis. So we've talked about implications for care based on surgical construction. Now we're going to talk briefly about implications for care based on anatomic location along the colon. So remember the function of the colon is to convert liquid stool to solid stool, to pull water and electrolytes back into the bloodstream. So obviously the closer the stoma is to the small bowel, the more liquid the drainage, the closer the stoma is to the rectum, the more formed the stool will be. So what about C-Costomy? So if you look at this diagram, a C-Costomy would be at the level of that little green section, just distal to the appendix. We very rarely see C-Costomy done. You may never see as a costomy. But if you have colonic obstruction and if the C-Combs extremely distended and if they're not able to take the patient in for any kind of definitive procedure because of other medical issues, you might see a C-Costomy done. Usually it's just a tube diversion. So they can do it all under local anesthesia where they just insert a large bore drainage tube into the cecum, just to decompress the colon. Many times there's leakage around that tube and you have to pouch around the tube. Occasionally, they'll do a minor surgical procedure. This is typically a patient whose palliative care and of life and their life, they're going to need this for the rest of their life and I don't trust a tube to work well is going to get clogged. So we can do this very minor surgical procedure where we attach the cecum to the abdominal wall. And of course, in that case, pouching would be essential. Now what kind of output would you have, very much like an Iliostomy? So fairly fluid, malodorous output, definitely the potential for fluid and electrolyte imbalance. So we have to look at adequate fluid intake. We would expect them to have output typically by the second post-op day, no later than the third post-op day. What about a stoma in the ascending colon? Again, very rare. We don't typically have these. But if we do, the stoma would be pretty close to the small bowel. So once again, we would have semi-liquid, malodorous stool. There would be the potential for fluid and electrolyte imbalance, or it would be critical to monitor fluid intake and overall output. Again, we would expect output to begin the second or third post-op day. and this patient would have to be managed with a drainable pouch, because they're going to have output throughout the day at unpredictable intervals. What about Estoma and the transverse colon? We used to see a lot of these, now they're relatively uncommon. So now you have Estoma kind of halfway between the small bowel and the rectum. Because of the time the stool is mushy, and typically they have output several times a day, a lot of bacteria, so a good bit of odor, so a secure pouch seal, and appropriate use of deodorants would be very important. Here's the really difficult thing about a transverse colostomy. This first colon is typically two to two and a half inches in diameter, so these are frequently large stomas. If a transverse colostomy is done because of obstruction in the descending sigmoid colon, then you're going to have distinction and edema, and then you can have a stoma that's three to four inches in diameter, that is huge, and overwhelming for the patient, it's like, oh my god, plus look at where a transverse stoma would be located, above the umbilicus. So in an area that's much more difficult to conceal, so if you have a very large stoma in the upper quadrants, you may have issues with pouching, you may have issues with concealment, you may have major issues with patient acceptance, and you're going to explain to the patient, this stoma is going to shrink over the next six to eight weeks, it's not going to always be this big. That doesn't help very much today, because I'm looking at it today, and I'm pretty overwhelmed, so a lot of patient support, you would expect output to begin between the third and fifth day, it's usually about the third day, sometimes fourth. You are going to manage with a drainable pouch again, output will be typically after meals and other unpredictable times, so definitely they will need a pouch at all times. The other thing you need to be aware of is it's fair, it's not uncommon to have prolapse of the distalumin of the stoma, and that again can lead to pouching problems, we'll actually discuss that more in a later class. Most colostomies are done in the descending or sigmoid colon, so typically they're located in the left lower quadrant, stool consistency is going to be very close to normal, so it's going to be typically soft to formed, and we have to be aware that because this stoma is very close to the rectum, this patient does have the potential for constipation, just like if they didn't have an ostomy, so we'll have to pay attention to fiber intake and fluid intake. On the positive side, stool from the descending sigmoid colon has no enzymes, so there's lower risk for skin irritation. Also, if you have a stoma located in the descending to sigmoid colon, output and function will mimic normal bowel function. And these patients actually have the option if they elect to do so to irrigate the stoma, to flush stool out of the bowel once a day or once every other day to control when the stoma empties, so they can actually choose to regulate stool output with routine irrigation. If they choose to do that and it's effective, then instead of wearing a drainable pouch, they can just use a small closed-in pouch, and we'll talk more about that in a later class. What about mucus fischula? So, just want to be sure that you're very clear on this term, so any time you see the term mucus fischula, it means that the distal, non-functioning portion of the bowel has been brought to the abdominal wall as a stoma. It's called a mucus fischula because that's all it produces. You can pouch it, but most of the time you can manage simply with addressing. So, in summary, when you're providing care for a patient with a colostomy, you have to consider how this stoma was constructed and where it was constructed. In terms of how it was constructed, if you have an end stoma with resection of the distal bowel, if this patient's undergoing abdominal perineal resection, then you know the ostomy's permanent and they'll have a perineal wound. If you have an end stoma with a heartman's pouch and you know this by reviewing the surgical report, you can't tell just by looking at them. Then you know there's the potential for reversible, for reversal, it's intended to be temporary and there's also the potential for intermittent mucus through the rectum. If you're having end stoma with a mucus fischula, uncommon, but in that case, you're going to pouch the proximal stoma, you're going to dress or pouch the distal stoma depending on is their output and how close is the distal stoma to the proximal stoma. Again, the potential for reversal. If you have a loop clostomy, potential for reversal always intended to be temporary. Always have the potential for periodic elimination of mucus from the rectum. You will have a temporary support to prevent retraction that's typically removed between five and fourteen days post-op. And then care based on anatomic location. If it's in the seagum or the asinine colon, you manage it very much like a niliostomy. You're going to have relatively fluid output increased risk for dehydration for fluid electrolyte imbalance. If it's located in the transverse colon, stool will be mushy, you'll have outputs several times a day, you'll have a large stoma that's more difficult to conceal. And if you have a stoma at the level of the descending or sigmoicolone stool will be very normal in consistency, patient will be higher risk for constipation, and the patient that's the one patient who has the option to regulate output with routine irrigation. Thank you very much.