A guide to stoma management

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Foreword

The fact that you have this book in your hand almost certainly means that you have either just had an operation for construction of an artificial anus or urine outlet or your doctor has told you that one of these operations is now unavoidable. In either case you will be seeking answers to a lot of questions.

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This guide gives you a brief explanation of the medical background to stoma operations and also advice on stoma management. FOR LIFE would be very pleased if its products help to mitigate your problems. It would also welcome your comments and suggestions. Our ears are always open.

Table of contents The digestive system Types of stoma Stoma management systems Stoma complications Stoma care Diet Stoma at work Stoma at play Notes

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The digestive system

Mouth

Oesophagus (gullet)

Liver

Large intestine

Stomach

Small intestine Rectum

Mouth and oesophagus Food is ingested through the mouth, where it is chewed into small pieces and mixed with saliva before being swallowed into the stomach via the oesophagus. Stomach The food arrives in the stomach in the form of a mush or slurry (the medical term for this mush is “chyme”), where it is mixed with gastric juices before passing through the pylorus into the duodenum, which is the first section of the small intestine. 04

Liver The liver produces the bile which is essential for digestion of fats, and injects it into the duodenum via the gall bladder. Small intestine The small intestine is divided into three sections: the duodenum, the jejunum and the ileum. In the duodenum the bile from the liver and the enzymes produced by the pancreas split up the nutrients in the food into their basic components. In this form the body can absorb them and use them to sustain life. This absorption process takes place in the next sections of the small intestine: the jejunum and the ileum. The substances that are essential for your body’s sustenance are absorbed into the blood through the intestinal wall. Large intestine or colon The undigested remains of the chyme pass from the ileum into the large intestine or colon and are normally quite liquid at this point. A substantial amount of this liquid is absorbed into the body through the walls of the colon. In this way, the undigested part of the diet thickens up and takes on the form of stools or faeces. Rectum The rectum follows the large intestine. Defecation takes place though the anus. 05

Types of stoma

The word stoma comes from the Greek and means “orifice” or “mouth”. Stoma is the medical term for a surgically constructed body orifice. This guide describes surgical procedures in which the small intestine, colon or ureter (the duct connecting the kidneys to the urinary bladder) are sutured (sewn) into the abdominal wall to form an artificial orifice through which body waste can be excreted. Intestinal stomata are sometimes called “anus praeter” (Latin for preternatural or artificial anus). The following types of stoma are possible:

Colostomy (colostoma): artificial opening into the colon

End colostomy

If a disease state makes it necessary to remove the lower section of the colon and also the rectum, anus and anal sphincter, a permanent end colostomy has to be constructed. The colon then ends at an artificial orifice in the abdominal wall. The colostomy is normally sited on the left side of the lower abdomen in the region of the descending colon. This operation leaves most of 06

the colon in place, and this means that the stools will normally be solid and formed on defecation. In cases where a relatively large section of colon has to be removed, the colostomy may have to be sited somewhere along the transverse colon. The loss of such a large section of the colon means that very little water has been absorbed from the intestinal contents and the body waste excreted through the stoma is more liquid.

Double-barrel colostomy

A double-barrel colostomy takes only part of the colon out of service. The aim is to rest the lower section of the intestinal tract and give it a chance to heal. Two artificial orifices are sutured into the abdominal wall. The faeces, often in fairly liquid state, are excreted through the upper stoma. The lower stoma is the end of the immobilised section of colon and exudes only mucus and intestinal cells. These can either be channelled on to the anal region and excreted in the natural way or collected at the stoma. If the affected section of the colon heals successfully and the anal sphincter has remained functional, this type of stoma can later be reversed. 07

Types of stoma

Ileostomy (ileostoma) – artificial opening into the small intestine

End ileostomy

In cases where the whole of the colon has to be removed, it is necessary to reroute the end of the small intestine to a stoma on the surface of the abdomen. This is called an ileostomy and the stoma is normally sited on the right side of the lower abdomen. As the colon is no longer absorbing water and making the stools more solid, the body waste excreted through the stoma is liquid and contains a high concentration of aggressive digestive enzymes which can cause irritation at the stoma exit.

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Double-barrel ileostomies are usually temporary, the aim being to rest certain lower sections of the intestinal tract. The stoma is usually sited on the right side of the lower abdomen. As with the double-barrel colostomy, a loop of the small intestine is pulled out of the abdomen. The intestine is then severed at a point in the loop and both ends are sutured into the abdominal wall. If the immobilised section of the intestinal tract heals successfully, the small intestine is then sewn together again and normal intestinal function can be resumed.

Double-barrel ileostomy

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Types of stoma

Urostomy (urostoma) – artificial opening into the ureter Urostomy enables excretion of urine through a stoma. The urinary organs are the body’s cleaning system. The kidneys filter out injurious and toxic degradation products from the blood. The final product of this filtering process is urine, which collects in the renal pelvis and flows from there through two ureters into the urinary bladder. The urine is temporarily stored in the urinary bladder until its excretion through the urethra. A urostomy becomes necessary when the urinary system is no longer capable of controlled urination because either the bladder or the urinary tract has been damaged or removed.

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Urostomy

Most urostomata are nowadays installed in the form of an ileum conduit. This is one of the classic procedures used to reroute urinary excretion and is considered safer than other surgical options, as well as being less likely to cause complications. The ileum conduit operation requires excision of a segment of the small intestine. Both ureters are then sutured into one end of this segment. The other end leads to a stoma in the abdominal wall. This is usually sited on the right side of the lower abdomen. The urine flows out of the renal pelvis through the ureters into the conduit and from there to the stoma on the surface of the abdomen, from where it drains off into the pouch.

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Stoma management systems

What you need is a reliable stoma management system which is tolerated well by your body and fitted with an effective deodorising filter system. When taking decisions on the type of management system described in this section, stoma patients should seek advice from experts. These are usually medically qualified persons and trained nurses specialising in stoma care.

Management systems for different types of stoma: • Closed-end pouches (also called bags) • Open-end pouches (drainable pouches) • Urostomy pouches Each of the foregoing products is available as: • A one-piece pouching system • A two-piece pouching system Each management system comes with its own range of accessories (see page 18). A special method can be used in certain cases to manage colostomies: • Colonic irrigation or intestinal lavage

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Closed-end pouches Closed-end pouches are made of either transparent or skincoloured soft plastic foil. An opening on one side of the pouch is surrounded by an adhesive surface. After removal of the protective strip from the adhesive surface, this must be pressed firmly onto the abdomen around the stoma, making sure that the skin around the stoma is not exposed to the body waste excretions.

The pouch is changed when full. Closed-end pouches are the management system normally used for colostomies. They have an integrated deodorising filter.

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Stoma management systems

Open-end pouches (drainable pouches) The main difference between the open-end and the closed-end pouch is that the open-end pouch has a second, resealable opening on the underside.

The pouch is emptied by opening this second hole and squeezing out the contents of the pouch while it is still attached to the body.

Open-end pouches are mainly used by ileostomy patients, because the body waste excreted from ileostomies is more liquid.

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Urostomy pouches The special features of the urostomy pouch are its in-built nonreturn valve and its outlet valve on the underside.

The non-return valve prevents urine reflux into the stoma. This is important to avoid the risk of inflammation of the urinary tract.

The pouch is emptied by opening the outlet (discharge) valve. An adapter is available for connection of a night bag or a leg bag to the outlet valve.

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Stoma management systems

One-piece systems In one-piece management systems the pouch and the base plate protecting the skin are a single unit. The pouch is stuck directly onto the skin with the adhesive surface of the base plate. The whole pouching system is removed when the pouch is changed.

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Two-piece systems In two-piece management systems the protective plate (often called the base plate) and the pouch are separate components. This makes it possible to change the pouch without disturbing the base plate. The pouch is either stuck onto the base plate or securely attached to it with a snap-fit ring closure.

The base plate can remain in place on the skin for several pouch changes.

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Stoma management systems

Accessories Various accessories are available to facilitate stoma management. The most frequently used are skin protection paste, skin protection rings, stoma belts and filter protectors. Skin-protection pastes and protective rings shield the skin around the stoma against the aggressive substances often present in body waste and can be used to form a protective coating on any exposed skin between the stoma and the protective base plate. Filter protectors prevent moisture from interfering with correct filter function.

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Colonic irrigation (intestinal lavage) Some colostomy patients can benefit from colonic irrigation.

This so-called lavage empties the intestines completely and is followed by a period during which no body waste is excreted. It is not necessary to wear a stoma pouch during this period.

When no pouch is being worn, use of a discreet stoma cap is recommended.

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Stoma complications

Bleeding Slight bleeding can sometimes occur from the mucous membranes forming the surface of the stoma. This is not normally serious but, if the bleeding is coming from deeper in the intestine itself, you should consult a doctor immediately.

Retraction If a stoma retracts, it pulls skin into the orifice and this skin is then exposed to the aggressive substances in the body waste. This can cause inflammation of the skin. In order to prevent retraction from causing management problems, a special pouching system with a conical base plate has been designed. Skin-protection pastes and stoma belts are often used as additional aids to prevent skin damage.

Stenosis (constriction of the stoma) Significant constriction of a stoma can cause abdominal cramps and evacuation problems. Stenosis is usually caused by formation of scar tissue following lengthy periods of inflammation.

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Prolapse This is the medical term for a stoma that turns inside out and protrudes from the surface of the abdomen.

Hernia (rupture of the abdominal wall) A hernia or rupture of the abdominal wall causes part of the peritoneum to protrude through the gap formed by the rupture. The peritoneum is a membrane lining the walls of the abdominal cavity. A bulge in the area around the stoma is usually a sure sign of a hernia. During the operation for construction of the stoma the surgeon has to cut through skin, connective tissue and muscle. This can weaken those tissues and make them less elastic. Major physical stress, like lifting heavy objects or strong pressing, can cause loops of the intestine to squeeze through the hernial orifice and form the bulge.

If you experience any of these complications, you should consult your doctor or stoma specialist immediately.

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Stoma care

Choice of management system Modern stoma management systems should be odour-proof, tear-resistant, skin-compatible, discreet and easy to use. The following points should be remembered when choosing your management system:

Type of stoma and consistency of excreted matter Colostomy patients normally use either one-piece or two-piece closed-end pouches. Most ileostomy patients use either one-piece or two-piece openend pouches (drainable pouches) that can be reused. Urostomy patients use urostomy bags fitted with a non-return valve and an outlet (discharge) valve.

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Skin care The most important skin care precautions can be summarised as follows: • Choice of optimal products made of skin-compatible materials • Choice of base plate with correct aperture size • Creation of an unbroken barrier protecting any exposed skin between the base plate and the stoma • Avoidance of aggressive detergents when cleaning the stoma – use either water only or soap not containing a re-fatting agent • Care when detaching the base plate from the skin

Skin reactions Skin inflammation and irritation can be caused by: allergies to materials used and substances contained in the stoma management products. They will normally be limited to skin that is in direct contact with the allergen and are characterised by skin reddening, blisters and itching. If the reaction is allergic, it is advisable to try switching to an alternative product.

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Stoma care

Irritation through contact with excreted body waste. This can often be eliminated by checking the base plate for optimal aperture size. A check whether any skin around the stoma is still exposed after adjustment of the aperture size is also recommended. It is advisable in some cases to enhance skin protection by using a skin-protection paste or a protective ring. When cleaning the stoma, use either water only or water with soap not containing a re-fatting agent.

Inflammation of hair follicles (folliculitis) It is preferable to shave the hairs in the vicinity of the stoma regularly, otherwise they tend to get pulled out when pouching systems are changed. This can cause folliculitis.

Fungal infections Yellowish-white patches on the mucous membranes can point to a fungal infection. If you see any symptoms of this kind, you should consult a doctor.

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Changing the pouching system Preparation: • Clean the skin around the stoma with a soft cloth and dab it dry • When cleaning the skin, do not use any products containing a re-fatting agent, because these can adversely affect adhesion of the base plate and other products designed to protect the skin • Check the diameter of the stoma • Select a base plate with the same aperture size as the stoma • If necessary, use the Stomocur scissors to trim the aperture in the base plate to the correct size

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Stoma care

Changing a one-piece system

• Remove the strip covering the adhesive side of the base plate

• Starting from below the stoma, stick the base plate carefully from bottom to top onto the skin surrounding the stoma

• Then run your fingers around the upper surface of the base plate and press it on cautiously

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Changing a two-piece system with snap-fit ring In systems using a snap-fit ring closure the base plate and the pouch each have a plastic ring. • Remove the strip covering the adhesive side of the base plate

• Starting from below the stoma, stick the base plate carefully from bottom to top onto the skin surrounding the stoma and press it on with your hands

• Use slight pressure to snap-fit the rings together

• This type of two-piece system is fitted with a small tongue that you must pull to release a full pouch from the base plate 27

Diet

Stoma patients do not need to follow a special diet, except where this is essential for some other reason, e.g. diabetes, Crohn’s disease (regional enteritis). But you should try to keep to a balanced diet. In addition, you should stay as physically active as possible and drink between 1.5 and 2 litres daily. It is also advisable to keep to a light diet during the period following the operation, eating light dishes spread over 4 to 6 portions per day. After a few weeks, you will normally be able to revert to your usual diet. If you do have any digestion problems or are not sure what you are allowed to eat, you should consult your doctor or stoma specialist.

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Stoma at work

Even while still in hospital, you will probably be wondering whether you will be able to return to your job after convalescence. The doctor treating you will be able to tell you whether your general state of health and the effects of the operation will enable you to return to your existing job. A job and the time spent at work are an important part of the life of just about everyone in the working population, and this is no different for stoma patients. They, like others, will in most cases want to keep on working. Many stoma patients are able to resume their former employment after the operation, either in full or with a certain number of restrictions. This will, of course, only be possible if they have learned to manage their stoma and are familiar with the various self-help procedures. A facility equipped to help them in case of emergencies should also be available somewhere in the vicinity of their workplace. You will also need to consider whether to tell your immediate superior and the people with whom you work very closely that you now have a stoma. 30

That will normally ensure a sympathetic reaction in cases where you suddenly need to make a quick change of pouch. But it is, of course, your decision (and your decision alone) whether to disclose this intimate information. And it is not in any way essential to do this, because the sophisticated stoma management systems now available are made of reliable materials and function odour-free when used correctly.

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Stoma at play

Sport Stoma patients are encouraged to stay as physically active as possible, both at work and in their everyday lives, and this applies to sport as well. Physical exertion within reasonable limits is recommended, both at work and at play. The only exceptions are extreme sporting activities like strength events, martial arts, apparatus gymnastics and athletics involving jumping or throwing. The following sporting activities are recommended: swimming, running, skiing, gymnastics and cycling.

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Travel There is no reason to avoid travelling, provided that you take the following precautions: • Take with you double the number of stoma pouches and, where applicable, base plates that you would normally need for the planned period of absence. • If you are travelling by plane or by rail with checked-in baggage, be sure to pack all your stoma products in your hand baggage so that they are always available if your registered baggage gets lost or delayed. • If you are travelling to another country, take a supply of drainable bags. Exotic foods and culinary practices can sometimes cause soft stools, even in colostomy patients.

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Notes

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As at: October 2014

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