PROCTOLOGIA - Ileostomy or colostomy care and complications - UpToDate - 2024

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<p>03/03/2024, 18:05 Ileostomy or colostomy care and complications - UpToDate</p><p>https://www.uptodate.com/contents/ileostomy-or-colostomy-care-and-complications/print?search=colostomy&source=search_result&selectedTitl… 1/33</p><p>Official reprint from UpToDate</p><p>www.uptodate.com © 2024 UpToDate, Inc. and/or its affiliates. All Rights Reserved.</p><p>Ileostomy or colostomy care and complications</p><p>INTRODUCTION</p><p>Ileostomy or colostomy creation may be required temporarily or permanently for the</p><p>management of a variety of pathologic conditions, including congenital anomalies, colon</p><p>obstruction, inflammatory bowel disease, intestinal trauma, or gastrointestinal malignancy</p><p>[1].</p><p>The anatomic location and type of stoma construction have an impact on management. Loop</p><p>colostomies tend to be larger and somewhat more difficult to manage than end colostomies.</p><p>The type and volume of output (effluent), and therefore fluid loss, is determined by the</p><p>location of the stoma relative to the ileocecal valve. Fluid loss is primarily a factor with end or</p><p>loop ileostomies.</p><p>With proper stoma care and attention to nutrition and fluid management, most ostomy</p><p>patients are able to have full, healthy, active social and professional lives and normal sexual</p><p>activity. In many cases, quality of life can be improved, even in the context of a permanent</p><p>ostomy, with treatment of the underlying disease.</p><p>The routine care and management of common issues and complications of stoma creation</p><p>are reviewed here. The types and indications, and principles of ostomy construction and</p><p>reversal, are discussed separately. (See "Overview of surgical ostomy for fecal diversion" and</p><p>"Parastomal hernia".)</p><p>PATIENT EDUCATION</p><p>®</p><p>�������: Ron G Landmann, MD, A Lee Cashman, RN, CWON</p><p>������� ������: Martin Weiser, MD</p><p>������ ������: Wenliang Chen, MD, PhD</p><p>All topics are updated as new evidence becomes available and our peer review process is complete.</p><p>Literature review current through: Feb 2024.</p><p>This topic last updated: Jan 02, 2024.</p><p>https://www.uptodate.com/</p><p>https://www.uptodate.com/contents/ileostomy-or-colostomy-care-and-complications/abstract/1</p><p>https://www.uptodate.com/contents/overview-of-surgical-ostomy-for-fecal-diversion?search=colostomy&topicRef=1384&source=see_link</p><p>https://www.uptodate.com/contents/parastomal-hernia?search=colostomy&topicRef=1384&source=see_link</p><p>https://www.uptodate.com/contents/ileostomy-or-colostomy-care-and-complications/contributors</p><p>https://www.uptodate.com/contents/ileostomy-or-colostomy-care-and-complications/contributors</p><p>https://www.uptodate.com/contents/ileostomy-or-colostomy-care-and-complications/contributors</p><p>https://www.uptodate.com/contents/ileostomy-or-colostomy-care-and-complications/contributors</p><p>https://www.uptodate.com/home/editorial-policy</p><p>03/03/2024, 18:05 Ileostomy or colostomy care and complications - UpToDate</p><p>https://www.uptodate.com/contents/ileostomy-or-colostomy-care-and-complications/print?search=colostomy&source=search_result&selectedTitl… 2/33</p><p>Patient preparation for adaptation to life with a temporary or permanent ostomy begins in</p><p>the preoperative period, whenever possible. (See "Overview of surgical ostomy for fecal</p><p>diversion", section on 'Preparation and counseling'.)</p><p>The patient must adapt to new patterns of fecal elimination and to their altered body and</p><p>image of themselves. Successful adaptation requires the patient to master new skills and to</p><p>deal effectively with the many emotional issues associated with their altered anatomy and</p><p>with altered continence. Interventions that promote adaptation include:</p><p>POUCH SYSTEMS AND ROUTINE OSTOMY CARE</p><p>Pouch systems — The main functions of ostomy pouches are to contain the ostomy effluent,</p><p>contain odor, and protect the peristomal skin. Many pouching systems are available as either</p><p>one- or two-piece systems:</p><p>One-piece systems offer simplicity, and many of these systems provide flexibility, which is</p><p>important for the patient whose stoma is located in a deep crease. Two-piece systems have</p><p>Preoperative stoma site selection by ostomy nurse specialist (enterostomal therapy</p><p>nurse, wound ostomy continence nurse) or experienced surgeon. Preoperative stoma</p><p>site marking has been associated with fewer ostomy-related complications (eg, leakage,</p><p>dermatitis), improved patients' ability to care for the ostomy independently, and</p><p>reduced health care costs [2]. Position papers by both the American Society of Colon</p><p>and Rectal Surgeons (ASCRS) and Wound Ostomy Continence Nurse Society (WOCN)</p><p>have been published to guide proper stoma site markings [3]. (See "Overview of</p><p>surgical ostomy for fecal diversion", section on 'Site selection and marking'.)</p><p>●</p><p>A strong focus on individualized patient education, with a preoperative and</p><p>postoperative component [2].</p><p>●</p><p>Supportive counseling for all patients preoperatively and in-depth counseling for any</p><p>patient who is having trouble adapting [4,5]. A number of studies have demonstrated</p><p>that involvement of an ostomy nurse specialist has a significant impact on long-term</p><p>positive outcomes and reduced complication rates, as does involvement in ostomy</p><p>support groups such as the United Ostomy Association of America [6-12].</p><p>●</p><p>One-piece systems include a protective skin barrier with a tape border fused to an</p><p>odor-proof pouch.</p><p>●</p><p>Two-piece systems include a protective skin barrier with a tape border and flange or</p><p>adhesive landing zone to which the patient attaches a separate odor-proof pouch.</p><p>●</p><p>https://www.uptodate.com/contents/overview-of-surgical-ostomy-for-fecal-diversion?sectionName=PREPARATION%20AND%20COUNSELING&search=colostomy&topicRef=1384&anchor=H21062994&source=see_link#H21062994</p><p>https://www.uptodate.com/contents/overview-of-surgical-ostomy-for-fecal-diversion?sectionName=PREPARATION%20AND%20COUNSELING&search=colostomy&topicRef=1384&anchor=H21062994&source=see_link#H21062994</p><p>https://www.uptodate.com/contents/ileostomy-or-colostomy-care-and-complications/abstract/2</p><p>https://www.uptodate.com/contents/ileostomy-or-colostomy-care-and-complications/abstract/3</p><p>https://www.uptodate.com/contents/overview-of-surgical-ostomy-for-fecal-diversion?sectionName=Site%20selection%20and%20marking&search=colostomy&topicRef=1384&anchor=H21063010&source=see_link#H21063010</p><p>https://www.uptodate.com/contents/overview-of-surgical-ostomy-for-fecal-diversion?sectionName=Site%20selection%20and%20marking&search=colostomy&topicRef=1384&anchor=H21063010&source=see_link#H21063010</p><p>https://www.uptodate.com/contents/ileostomy-or-colostomy-care-and-complications/abstract/2</p><p>https://www.uptodate.com/contents/ileostomy-or-colostomy-care-and-complications/abstract/4,5</p><p>https://www.uptodate.com/contents/ileostomy-or-colostomy-care-and-complications/abstract/6-12</p><p>03/03/2024, 18:05 Ileostomy or colostomy care and complications - UpToDate</p><p>https://www.uptodate.com/contents/ileostomy-or-colostomy-care-and-complications/print?search=colostomy&source=search_result&selectedTitl… 3/33</p><p>the advantage that the pouch can be replaced without having to remove the protective skin</p><p>barrier each time.</p><p>Pouch placement — The patient should be taught strategies that can help promote pouch</p><p>adherence to the skin, minimize leakage, and protect peristomal skin. These include:</p><p>Pouch emptying and care — Odor and gas are common concerns for any individual with an</p><p>ostomy [15]. The patient should be assured that ostomy pouches are odor proof, but when</p><p>the pouch is emptied, odor is normal. Simple strategies can help reduce odor. These include</p><p>the following:</p><p>Selecting a pouching system that conforms to the abdominal contour at the stoma</p><p>location. As examples:</p><p>●</p><p>A flat pouch with a rigid flange requires a relatively flat, at least 4 cm pouching</p><p>surface that is distant from scars, skin creases or folds, and bony prominences [13].</p><p>•</p><p>A stoma located in a concave abdominal plane may be best managed with a convex</p><p>pouching system, which can increase protrusion of the stoma and improve drainage</p><p>of effluent into the pouch.</p><p>•</p><p>Transverse loop colostomies are typically large stomas in the upper quadrants that</p><p>(See 'Diet and control of gas'</p><p>above.)</p><p>Managing high ostomy output – Patients with ileostomies or ascending or transverse</p><p>colostomies should be taught to (see 'Ileostomy patients' above):</p><p>●</p><p>Increase daily fluid intake by 500 to 750 mL beyond the recommended average</p><p>intake for the general population to prevent dehydration or electrolyte imbalance.</p><p>(See 'Dehydration' above.)</p><p>•</p><p>Take soluble fiber supplements or antimotility agents for persistent high ostomy</p><p>output (>1.5 L/day). (See 'High ostomy output' above.)</p><p>•</p><p>Consume small quantities of food items with high insoluble fiber content to prevent</p><p>food blockage proximal to the stoma. (See 'Food blockage' above.)</p><p>•</p><p>Take medications in dosage forms of quick dissolution (eg, liquids, gelatin capsules,</p><p>and uncoated tablets) and avoid time-released and enteric-coated medications, as</p><p>well as very large tablets, to avoid drug malabsorption. (See 'Drug malabsorption'</p><p>above.)</p><p>•</p><p>Managing constipation – Although there are no absolute dietary restrictions for</p><p>descending or sigmoid colostomy patients, patients should be encouraged to ingest</p><p>sufficient fiber (20 to 35 g/day) and fluids (at least 1.5 to 2 L/day) to prevent</p><p>constipation. If constipation does occur, it can be managed with laxatives, stoma</p><p>disimpaction, or colonic irrigation (for distal colostomy patients only). (See 'Colostomy</p><p>patients' above.)</p><p>●</p><p>Managing stomal complications – Nearly half of all stomas eventually become</p><p>"problematic" due to pouching and peristomal skin issues. Complications vary with type</p><p>of ostomy (loop>end; ileostomy>colostomy) and the time from construction (see</p><p>'Ostomy complications' above):</p><p>●</p><p>Early (<3 months) complications include stomal ischemia/necrosis, stomal bleeding,</p><p>stomal retraction, and mucocutaneous separation. (See 'Early complications (<3</p><p>months)' above.)</p><p>•</p><p>Late (>3 months) complications include parastomal hernia, stomal prolapse, and</p><p>stoma stenosis. (See 'Late complications (>3 months)' above.)</p><p>•</p><p>Peristomal skin breakdown, which can vary in severity from minor skin trauma, to</p><p>dermatitis, to ulceration, to granulomas, and to pyoderma gangrenosum (in</p><p>inflammatory bowel disease or cancer patients), can occur early or late and is more</p><p>•</p><p>03/03/2024, 18:05 Ileostomy or colostomy care and complications - UpToDate</p><p>https://www.uptodate.com/contents/ileostomy-or-colostomy-care-and-complications/print?search=colostomy&source=search_result&selectedTi… 20/33</p><p>ACKNOWLEDGMENT</p><p>The UpToDate editorial staff acknowledges Dorothy Doughty, MN, RN, CWOCN, FAAN, who</p><p>contributed to earlier versions of this topic review.</p><p>Use of UpToDate is subject to the Terms of Use.</p><p>REFERENCES</p><p>1. Doughty D. Principles of ostomy management in the oncology patient. J Support Oncol</p><p>2005; 3:59.</p><p>2. Hendren S, Hammond K, Glasgow SC, et al. 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UpToDate</p><p>https://www.uptodate.com/contents/ileostomy-or-colostomy-care-and-complications/print?search=colostomy&source=search_result&selectedTi… 25/33</p><p>GRAPHICS</p><p>Dietary influences on stoma function</p><p>Increase odor</p><p>Beans</p><p>Asparagus</p><p>Broccoli</p><p>Brussel sprouts</p><p>Cauliflower</p><p>Cabbage</p><p>Eggs</p><p>Fish</p><p>Onions</p><p>Some spices</p><p>Increase gas</p><p>Beans</p><p>Beer, carbonated soda</p><p>Broccoli</p><p>Brussel sprouts</p><p>Cauliflower</p><p>Cabbage</p><p>Corn</p><p>Cucumbers</p><p>Mushrooms</p><p>Peas</p><p>Radishes</p><p>Spinach</p><p>Dairy products</p><p>Thicken stool</p><p>Apple sauce</p><p>Bananas</p><p>Cheese</p><p>Boiled milk</p><p>Marshmallows</p><p>Pasta</p><p>Creamy peanut butter</p><p>Pretzels</p><p>Rice</p><p>Bread</p><p>Tapioca</p><p>Toast</p><p>Yogurt</p><p>Loosen stool</p><p>Green beans</p><p>Beer</p><p>Broccoli</p><p>Fresh fruits</p><p>Grape juice</p><p>Raw vegetables</p><p>Prunes</p><p>Spicy foods</p><p>Fried foods</p><p>Chocolate</p><p>Leafy green vegetables</p><p>Spinach</p><p>Graphic 64218 Version 1.0</p><p>03/03/2024, 18:05 Ileostomy or colostomy care and complications - UpToDate</p><p>https://www.uptodate.com/contents/ileostomy-or-colostomy-care-and-complications/print?search=colostomy&source=search_result&selectedTi… 26/33</p><p>Antimotility agents used for high-output fistulas</p><p>Drug</p><p>Initial</p><p>dose</p><p>Route Frequency Titration Max dose C</p><p>Loperamide 4 mg PO Three times</p><p>daily with</p><p>meals or</p><p>every 6</p><p>hours with</p><p>enteral</p><p>nutrition</p><p>By 2 mg 16 mg/day</p><p>Diphenoxylate/atropine 2.5</p><p>mg/0.025</p><p>mg</p><p>(1 tablet)</p><p>PO Three times</p><p>daily with</p><p>meals or</p><p>every 6</p><p>hours with</p><p>enteral</p><p>nutrition</p><p>By 1 tablet 2 tablets four</p><p>times daily</p><p>(20 mg</p><p>diphenoxylate)</p><p>Pantoprazole 40 mg IV Twice daily None 40 mg twice</p><p>daily</p><p>Codeine 15 mg PO Three times</p><p>daily with</p><p>meals, up to</p><p>four times</p><p>daily</p><p>By 15 mg 45 mg four</p><p>times daily</p><p>Octreotide 100 mcg SC Three times</p><p>daily</p><p>None None</p><p>Clonidine 0.3 mg Transdermal Every 7 days None 0.3 mg every 7</p><p>days</p><p>$</p><p>PO: oral; IV: intravenous; CNS: central nervous system; SC: subcutaneous; HR: heart rate; BP: blood</p><p>pressure.</p><p>* Prices estimated based on approximate inpatient acquisition cost:</p><p>$: less than $1 per day</p><p>$$: more than $1 per day</p><p>$$$: more than $5 per day</p><p>$$$$: more than $10 per day</p><p>Reproduced from: Parli SE, Pfeifer C, Oyler DR, et al. Redefining "bowel regimen": Pharmacologic strategies and nutritional</p><p>considerations in the management of small bowel fistulas. Am J Surg 2018; 216:351. Table used with the permission of Elsevier</p><p>Inc. All rights reserved.</p><p>03/03/2024, 18:05 Ileostomy or colostomy care and complications - UpToDate</p><p>https://www.uptodate.com/contents/ileostomy-or-colostomy-care-and-complications/print?search=colostomy&source=search_result&selectedTi… 27/33</p><p>Graphic 119176 Version 1.0</p><p>03/03/2024, 18:05 Ileostomy or colostomy care and complications - UpToDate</p><p>https://www.uptodate.com/contents/ileostomy-or-colostomy-care-and-complications/print?search=colostomy&source=search_result&selectedTi… 28/33</p><p>Retracted end sigmoid colostomy</p><p>A flush or retracted stoma is undesirable because it may require more specialized equipment or</p><p>additional accessories to aid in the appliance fit and therefore facilitate drainage.</p><p>Courtesy of Jeffrey B Matthews, MD.</p><p>Graphic 81992 Version 1.0</p><p>03/03/2024, 18:05 Ileostomy or colostomy care and complications - UpToDate</p><p>https://www.uptodate.com/contents/ileostomy-or-colostomy-care-and-complications/print?search=colostomy&source=search_result&selectedTi… 29/33</p><p>Irritant contact dermatitis</p><p>Exposure to damaging effluent can produce severe skin breakdown in the area exposed to the</p><p>drainage; this type of skin damage is characterized by severely denuded skin along the inferior aspect</p><p>of the stoma and is most common among ileostomy patients and patients with problematic stomas</p><p>(eg, stomas that are retracted and empty below skin level).</p><p>Courtesy of Dorothy B Doughty, MN, RN, CWOCN, FAAN.</p><p>Graphic 81549 Version 1.0</p><p>03/03/2024, 18:05 Ileostomy or colostomy care and complications - UpToDate</p><p>https://www.uptodate.com/contents/ileostomy-or-colostomy-care-and-complications/print?search=colostomy&source=search_result&selectedTi… 30/33</p><p>Peristomal fungal infection</p><p>Fungal infection presents as a maculopapular rash with distinct satellite lesions.</p><p>Courtesy of Dorothy B Doughty, MN, RN, CWOCN, FAAN.</p><p>Graphic 79045 Version 1.0</p><p>03/03/2024, 18:05 Ileostomy or colostomy care and complications - UpToDate</p><p>https://www.uptodate.com/contents/ileostomy-or-colostomy-care-and-complications/print?search=colostomy&source=search_result&selectedTi…</p><p>31/33</p><p>Allergic contact dermatitis</p><p>Allergic reactions can occur with any of the products used to protect the peristomal skin or to assure</p><p>adhesion of the pouching system; allergic reactions are characterized by pruritus, erythema, and</p><p>blistering in the area corresponding to contact with the offending agent.</p><p>Courtesy of Dorothy B Doughty, MN, RN, CWOCN, FAAN.</p><p>Graphic 68947 Version 1.0</p><p>03/03/2024, 18:05 Ileostomy or colostomy care and complications - UpToDate</p><p>https://www.uptodate.com/contents/ileostomy-or-colostomy-care-and-complications/print?search=colostomy&source=search_result&selectedTi… 32/33</p><p>Pyoderma gangrenosum</p><p>Peristomal pyoderma gangrenosum is caused by an inflammatory process that produces severe and</p><p>painful skin ulcerations.</p><p>Courtesy of Dorothy B Doughty, MN, RN, CWOCN, FAAN.</p><p>Graphic 72285 Version 2.0</p><p>03/03/2024, 18:05 Ileostomy or colostomy care and complications - UpToDate</p><p>https://www.uptodate.com/contents/ileostomy-or-colostomy-care-and-complications/print?search=colostomy&source=search_result&selectedTi… 33/33</p><p>Contributor Disclosures</p><p>Ron G Landmann, MD No relevant financial relationship(s) with ineligible companies to disclose. A</p><p>Lee Cashman, RN, CWON No relevant financial relationship(s) with ineligible companies to</p><p>disclose. Martin Weiser, MD Consultant/Advisory Boards: PrecisCa [Gastrointestinal surgical</p><p>oncology]. All of the relevant financial relationships listed have been mitigated. Wenliang Chen, MD,</p><p>PhD No relevant financial relationship(s) with ineligible companies to disclose.</p><p>Contributor disclosures are reviewed for conflicts of interest by the editorial group. When found, these</p><p>are addressed by vetting through a multi-level review process, and through requirements for</p><p>references to be provided to support the content. Appropriately referenced content is required of all</p><p>authors and must conform to UpToDate standards of evidence.</p><p>Conflict of interest policy</p><p></p><p>https://www.uptodate.com/home/conflict-interest-policy</p><p>are difficult to conceal, and prolapse is more common. (See 'Stomal prolapse' below.)</p><p>•</p><p>Cecostomies, now rarely performed, are typically skin-level stomas located adjacent</p><p>to the groin crease, which compromises pouch adherence.</p><p>•</p><p>Sizing the opening of the protective skin barrier to minimize the amount of exposed</p><p>skin. Stomas often change shape and size in the postoperative period. After the stoma</p><p>has assumed its final appearance (usually several weeks after construction), a precut</p><p>protective skin barrier may be supplied so the patient or their caregivers do not need to</p><p>cut out the skin barrier each time a new appliance is placed.</p><p>●</p><p>Using adjunctive products to improve the fixation of the pouch (adhesive agents, Skin</p><p>Prep) and to prevent irritation and injury to the peristomal skin (skin barrier paste, skin</p><p>barrier powder, skin barrier ring) [6,14].</p><p>●</p><p>Loop ileostomies are typically more difficult to manage than end ileostomies because</p><p>the stoma frequently empties close to the skin surface. Because the small bowel</p><p>effluent is rich in proteolytic enzymes, the patient with an ileostomy must exercise</p><p>particular caution in managing the peristomal skin. These patients should routinely use</p><p>barrier wafers, rings, and/or paste to assure that their skin is not exposed to the</p><p>drainage and must treat any minor skin damage aggressively to prevent progression.</p><p>●</p><p>https://www.uptodate.com/contents/ileostomy-or-colostomy-care-and-complications/abstract/15</p><p>https://www.uptodate.com/contents/ileostomy-or-colostomy-care-and-complications/abstract/13</p><p>https://www.uptodate.com/contents/ileostomy-or-colostomy-care-and-complications/abstract/6,14</p><p>03/03/2024, 18:05 Ileostomy or colostomy care and complications - UpToDate</p><p>https://www.uptodate.com/contents/ileostomy-or-colostomy-care-and-complications/print?search=colostomy&source=search_result&selectedTitl… 4/33</p><p>If odor is a particular concern for the patient, bismuth subgallate or chlorophyllin copper</p><p>complex effectively reduces stool odor when taken routinely [14].</p><p>DIET AND CONTROL OF GAS</p><p>Many patients assume that they will have to adhere to a special diet because of their ostomy.</p><p>Dietary modifications are usually minimal, but specific foods can influence the amount of the</p><p>gas and the consistency and odor of the effluent [11,16]. Patients should be given a general</p><p>list of gas-producing foods ( table 1). The carbohydrate raffinose is poorly digested and</p><p>leads to gas production by the action of colonic bacteria. Common foods containing raffinose</p><p>include beans, cabbage, cauliflower, brussel sprouts, broccoli, and asparagus. Starch and</p><p>soluble fiber are other forms of carbohydrates that can contribute to gas formation.</p><p>Potatoes, corn, noodles, and wheat produce gas, while rice does not. Soluble fiber (found in</p><p>oat bran, peas and other legumes, beans, and most fruit) also causes gas.</p><p>Patients should also be given an explanation that the usual "lag time" between ingestion of a</p><p>gas-producing food and actual flatulence is between two and four hours for ileostomy and</p><p>six to eight hours for distal colostomy. In addition to dietary modifications, ileostomy</p><p>patients should be taught to avoid drinking carbonated drinks, drinking through straws,</p><p>chewing gum, and smoking, since these measures tend to increase gas ingestion.</p><p>Strategies to control gas include measures to reduce the volume of gas produced or to affect</p><p>the "timing" of flatulence, "muffling" measures, and "venting" strategies. Dietary</p><p>modifications and over-the-counter gas-reducing agents (eg, Beano and Gas-X) help reduce</p><p>the volume of gas. "Muffling" measures include layers of clothing and light pressure exerted</p><p>Emptying the pouch when it is approximately one-third full will prevent disruption of</p><p>the pouch seal from excess weight.</p><p>●</p><p>Changing the pouch one to two times weekly, and as needed, for any signs of leakage,</p><p>or for itching/burning of the peristomal skin.</p><p>●</p><p>Keeping the tail of the pouch clean so that it does not become a source of odor. This</p><p>can be accomplished by everting the tail of a pouch prior to emptying it. For some</p><p>pouches that have an integrated closure mechanism, tail eversion is not required.</p><p>●</p><p>Using a room spray or pouch deodorant to minimize odor associated with emptying.●</p><p>Bismuth subgallate tends to thicken the stool, so it may best be used for the patient</p><p>with an ileostomy or proximal colostomy.</p><p>●</p><p>Chlorophyllin may have a slight diarrheal effect and is more appropriate for the patient</p><p>with a descending/sigmoid colostomy.</p><p>●</p><p>https://www.uptodate.com/contents/bismuth-subgallate-drug-information?search=colostomy&topicRef=1384&source=see_link</p><p>https://www.uptodate.com/contents/ileostomy-or-colostomy-care-and-complications/abstract/14</p><p>https://www.uptodate.com/contents/ileostomy-or-colostomy-care-and-complications/abstract/11,16</p><p>https://www.uptodate.com/contents/image?imageKey=GAST%2F64218&topicKey=SURG%2F1384&search=colostomy&rank=1%7E101&source=see_link</p><p>https://www.uptodate.com/contents/image?imageKey=GAST%2F64218&topicKey=SURG%2F1384&search=colostomy&rank=1%7E101&source=see_link</p><p>https://www.uptodate.com/contents/beano-alpha-galactosidase-drug-information?search=colostomy&topicRef=1384&source=see_link</p><p>https://www.uptodate.com/contents/bismuth-subgallate-drug-information?search=colostomy&topicRef=1384&source=see_link</p><p>03/03/2024, 18:05 Ileostomy or colostomy care and complications - UpToDate</p><p>https://www.uptodate.com/contents/ileostomy-or-colostomy-care-and-complications/print?search=colostomy&source=search_result&selectedTitl… 5/33</p><p>against the stoma with the hand or arm when flatulence is anticipated. For patients with</p><p>large volumes of gas, there are pouching systems with filters, which vent and deodorize</p><p>flatus; there are also "add-on" flatus filters that can be used with any pouching system [6].</p><p>(See "Patient education: Gas and bloating (Beyond the Basics)".)</p><p>ILEOSTOMY PATIENTS</p><p>The type and volume of output (effluent), and therefore fluid loss, is determined by the</p><p>location of the stoma relative to the ileocecal valve. Ileostomies, cecostomies, and ascending</p><p>colostomies typically produce output (effluent) >500 mL per day that contains digestive</p><p>enzymes, which is irritating to the mucosa and skin [6,17].</p><p>Dehydration — Dehydration affects up to 30 percent of patients after loop ileostomy</p><p>creation and is the most common cause for hospital readmission after ileostomy surgery</p><p>[18,19].</p><p>How much fluid should an adult drink each day to prevent dehydration? It is a simple</p><p>question with no easy answer, as studies have produced varying recommendations. As</p><p>examples:</p><p>Regardless, patients with an ileostomy should be instructed to increase their daily fluid</p><p>intake beyond the recommended AI for the general population by at least 500 to 750 mL and</p><p>to drink even more during periods of high-volume output or heavy sweating. Preferred fluids</p><p>include water, broth, vegetable juices, and some sports drinks, but patients should be</p><p>advised that certain sports drinks may not be absorbed and may even exacerbate stoma</p><p>output and dehydration. The use of pediatric electrolyte solutions (eg, PediaLyte, Emergen-C)</p><p>is preferable to the use of sports drinks.</p><p>Ileostomy patients and patients with ascending colostomies should be taught the</p><p>importance of adequate daily fluid intake. Average output for the ileostomy patient ranges</p><p>The United States National Academies of Sciences, Engineering, and Medicine (formerly</p><p>the Institute of Medicine) have recommended adequate intake (AI) values for total</p><p>water at levels to prevent dehydration [20]. The AI for men aged 19+ is 3.7 liters each</p><p>day, 3 liters (13 cups) of which should be consumed as beverages. The AI for women</p><p>aged 19+ is 2.7 liters, about 2.2 liters (9 cups) of which should be consumed as</p><p>beverages each day.</p><p>●</p><p>The Eatwell guide of the British National Health Service (NHS) has recommended</p><p>drinking six to eight cups or glasses of fluid a day [21]. Each cup or glass generally</p><p>contains eight ounces of fluid. Thus, eight cups of fluid would add up to 64 ounces</p><p>or</p><p>approximately 1.9 liters.</p><p>●</p><p>https://www.uptodate.com/contents/ileostomy-or-colostomy-care-and-complications/abstract/6</p><p>https://www.uptodate.com/contents/gas-and-bloating-beyond-the-basics?search=colostomy&topicRef=1384&source=see_link</p><p>https://www.uptodate.com/contents/ileostomy-or-colostomy-care-and-complications/abstract/6,17</p><p>https://www.uptodate.com/contents/ileostomy-or-colostomy-care-and-complications/abstract/18,19</p><p>https://www.uptodate.com/contents/ileostomy-or-colostomy-care-and-complications/abstract/20</p><p>https://www.uptodate.com/contents/ileostomy-or-colostomy-care-and-complications/abstract/21</p><p>03/03/2024, 18:05 Ileostomy or colostomy care and complications - UpToDate</p><p>https://www.uptodate.com/contents/ileostomy-or-colostomy-care-and-complications/print?search=colostomy&source=search_result&selectedTitl… 6/33</p><p>from 500 to 1300 mL a day; during the early postoperative period and episodes of</p><p>gastroenteritis, daily output can be 1800 mL or even higher [22]. A loop ileostomy performed</p><p>in conjunction with a pelvic pouch procedure is located more proximally in the ileum and is</p><p>associated with even more fluid and enzymatic output. This daily fluid loss places the</p><p>ileostomy patient at greater risk for dehydration, especially during episodes of increased</p><p>output or heavy perspiration.</p><p>Ileostomy effluent contains significant amounts of sodium and potassium. Patients should</p><p>also be taught the signs and symptoms of fluid-electrolyte imbalance and the importance of</p><p>prompt treatment should these symptoms occur. These include dry mouth; reduced urine</p><p>output; dark, concentrated urine; feelings of dizziness upon standing; marked fatigue; and</p><p>abdominal cramping [14,23]. (See "Etiology, clinical manifestations, and diagnosis of volume</p><p>depletion in adults".)</p><p>Protocols and pathways have been proposed to minimize dehydration and readmission in</p><p>patients with new ileostomies. Using combinations of preoperative teaching; in-hospital</p><p>engagement of the nurses and Wound, Ostomy and Continence care (WOCN) teams; in-</p><p>hospital involvement and encouragement of patients and their caretakers in stoma care;</p><p>postdischarge counseling; and tracking of intake and output has effectively reduced hospital</p><p>readmission while maintaining an appropriate hospital length of stay [24].</p><p>High ostomy output — First-line management of patients with elevated ileostomy output</p><p>(defined as >1.5 L/day) should include soluble viscous, nonfermenting, gel-forming fiber</p><p>supplementation (eg, psyllium husk), which can slow transit time by absorbing water and</p><p>forming a gel-like consistency [25-27]. Patients may slowly increase supplementation up to</p><p>four times daily and also at double doses. By contrast, insoluble fiber supplements (eg,</p><p>Wheat Bran), also referred to as bulk-forming laxatives, can speed up transit time and are</p><p>primarily used to treat constipation.</p><p>Medical management of patients with inappropriately elevated ileostomy outputs is required</p><p>in patients who do not respond to fiber supplementation and includes antimotility agents</p><p>(eg, loperamide [Imodium], diphenoxylate and atropine [Lomotil], codeine, morphine, and</p><p>rarely, tincture of opium ( table 2)). We usually start with loperamide because it is over the</p><p>counter and has fewer side effects [28]. The starting dose for loperamide is one tablet two to</p><p>three times a day based on stoma output. In all cases, adjustments should be made slowly</p><p>and not in combination, as this could lead to a paralytic ileus or an obstructive pattern.</p><p>Anti-secretory agents can be added, including octreotide, proton pump inhibitors, and H2</p><p>antagonists. Bile acid binders such as cholestyramine may only serve to worsen fat</p><p>malabsorption and steatorrhea and should not be prescribed in patients with end</p><p>ileostomies [29].</p><p>https://www.uptodate.com/contents/ileostomy-or-colostomy-care-and-complications/abstract/22</p><p>https://www.uptodate.com/contents/ileostomy-or-colostomy-care-and-complications/abstract/14,23</p><p>https://www.uptodate.com/contents/etiology-clinical-manifestations-and-diagnosis-of-volume-depletion-in-adults?search=colostomy&topicRef=1384&source=see_link</p><p>https://www.uptodate.com/contents/etiology-clinical-manifestations-and-diagnosis-of-volume-depletion-in-adults?search=colostomy&topicRef=1384&source=see_link</p><p>https://www.uptodate.com/contents/ileostomy-or-colostomy-care-and-complications/abstract/24</p><p>https://www.uptodate.com/contents/psyllium-drug-information?search=colostomy&topicRef=1384&source=see_link</p><p>https://www.uptodate.com/contents/ileostomy-or-colostomy-care-and-complications/abstract/25-27</p><p>https://www.uptodate.com/contents/loperamide-drug-information?search=colostomy&topicRef=1384&source=see_link</p><p>https://www.uptodate.com/contents/atropine-drug-information?search=colostomy&topicRef=1384&source=see_link</p><p>https://www.uptodate.com/contents/codeine-drug-information?search=colostomy&topicRef=1384&source=see_link</p><p>https://www.uptodate.com/contents/morphine-drug-information?search=colostomy&topicRef=1384&source=see_link</p><p>https://www.uptodate.com/contents/opium-tincture-drug-information?search=colostomy&topicRef=1384&source=see_link</p><p>https://www.uptodate.com/contents/image?imageKey=SURG%2F119176&topicKey=SURG%2F1384&search=colostomy&rank=1%7E101&source=see_link</p><p>https://www.uptodate.com/contents/image?imageKey=SURG%2F119176&topicKey=SURG%2F1384&search=colostomy&rank=1%7E101&source=see_link</p><p>https://www.uptodate.com/contents/ileostomy-or-colostomy-care-and-complications/abstract/28</p><p>https://www.uptodate.com/contents/octreotide-drug-information?search=colostomy&topicRef=1384&source=see_link</p><p>https://www.uptodate.com/contents/cholestyramine-drug-information?search=colostomy&topicRef=1384&source=see_link</p><p>https://www.uptodate.com/contents/ileostomy-or-colostomy-care-and-complications/abstract/29</p><p>03/03/2024, 18:05 Ileostomy or colostomy care and complications - UpToDate</p><p>https://www.uptodate.com/contents/ileostomy-or-colostomy-care-and-complications/print?search=colostomy&source=search_result&selectedTitl… 7/33</p><p>Occasionally, patients may require intravenous fluid hydration as outpatients to compensate</p><p>for the fluid losses. The efficacy of the different management strategies for high ostomy</p><p>output is discussed in detail separately. (See "Enterocutaneous and enteroatmospheric</p><p>fistulas".)</p><p>Rarely, patients with difficult-to-control ileostomy output may need to be maintained on</p><p>intravenous hydration via a long-term indwelling venous access cannula. Those with</p><p>persistent, recurrent, or difficult-to-manage complications from loop ileostomy creation</p><p>should be considered for early reversal of the stoma and restoration of intestinal continuity,</p><p>when feasible.</p><p>Ileostomy patients with high output may need to change to a protective skin barrier that is</p><p>extended wear and/or the addition of a skin barrier ring to prevent washout of the skin</p><p>barrier. Also, changing to a high-output pouch would be beneficial for patient management.</p><p>Food blockage — Ileostomy patients should also be taught strategies to prevent food</p><p>blockage proximal to the ostomy site, which can occur because the ileal lumen is <1 inch (2.5</p><p>cm) in diameter. There is also the potential for further narrowing at the point where the</p><p>bowel passes through the fascia/muscle layer. If the patient consumes large amounts of</p><p>insoluble fiber, the undigested fiber may create an obstructing mass (bezoar). Common</p><p>"offenders" include popcorn, coconut, mushrooms, black olives, stringy vegetables, corn,</p><p>nuts, celery, foods with skins, dried fruits, and meats with casings.</p><p>Food blockage is easily prevented by instructing the patient to consume potential offenders</p><p>one at a time in small amounts, to chew thoroughly, and to monitor their response [6,23].</p><p>Drug malabsorption — Because the small bowel is the most important site of drug</p><p>absorption, patients with ileostomy are at risk for suboptimal drug absorption. The patient</p><p>with an ileostomy must be taught to take medications in dosage forms of quick dissolution,</p><p>such as liquids, gelatin capsules, and uncoated tablets, and avoid time-released</p><p>and enteric-</p><p>coated medications as well as very large tablets since these forms of medication are likely to</p><p>be incompletely absorbed. Consult with a pharmacist regarding medications that may not</p><p>dissolve or be absorbed appropriately. They must also avoid laxatives due to the risk for</p><p>acute dehydration [6].</p><p>COLOSTOMY PATIENTS</p><p>Descending/sigmoid colostomies produce stool that is formed and does not contain</p><p>digestive enzymes. Colostomy patients can be reassured that there are no absolute dietary</p><p>restrictions [30]. However, they should be encouraged to ingest sufficient fiber and fluids to</p><p>https://www.uptodate.com/contents/enterocutaneous-and-enteroatmospheric-fistulas?search=colostomy&topicRef=1384&source=see_link</p><p>https://www.uptodate.com/contents/enterocutaneous-and-enteroatmospheric-fistulas?search=colostomy&topicRef=1384&source=see_link</p><p>https://www.uptodate.com/contents/ileostomy-or-colostomy-care-and-complications/abstract/6,23</p><p>https://www.uptodate.com/contents/ileostomy-or-colostomy-care-and-complications/abstract/6</p><p>https://www.uptodate.com/contents/ileostomy-or-colostomy-care-and-complications/abstract/30</p><p>03/03/2024, 18:05 Ileostomy or colostomy care and complications - UpToDate</p><p>https://www.uptodate.com/contents/ileostomy-or-colostomy-care-and-complications/print?search=colostomy&source=search_result&selectedTitl… 8/33</p><p>prevent constipation and should also be counseled regarding gas-producing foods and lag</p><p>time. (See 'Diet and control of gas' above.)</p><p>Patients should be taught to prevent constipation by maintaining appropriate fiber (20 to 35</p><p>g/day) and fluid intake (at least 1.5 to 2 L/day). If constipation does occur, it can be managed</p><p>with laxatives or irrigation. (See "Management of chronic constipation in adults", section on</p><p>'Fiber' and 'Colon irrigation' below.)</p><p>For severe constipation, digital disimpaction of the colostomy may be necessary but should</p><p>only be performed by an experienced clinician or ostomy nurse.</p><p>The patient should also be informed that intermittent mucoid discharge is normal either</p><p>from the distal ostomy site (mucus fistula) or from the anus with ostomies that have a</p><p>defunctionalized distal limb.</p><p>Colon irrigation — Routine irrigation is appropriate only for patients with distal colostomies</p><p>and is not effective for all patients. Irrigation involves instillation of 500 to 1500 mL of tap</p><p>water into the descending or sigmoid colon ostomy on a routine schedule (usually daily or</p><p>every other day); the resulting bowel distention stimulates peristaltic activity, which causes</p><p>the distal colon to empty.</p><p>Patients who had fairly normal bowel elimination patterns preoperatively can usually achieve</p><p>complete evacuation of the colon with irrigation, which provides them with a "stool-free"</p><p>interval of approximately 24 hours. Most patients who manage their colostomies with</p><p>routine irrigation are essentially continent and need to wear only a small pouch or "cap" for</p><p>collection of mucous and deodorization of flatus. Patients who manage effectively with</p><p>routine irrigation report a higher quality of life than patients who manage with pouching</p><p>[6,11,31-33]. Some have raised concerns that routine irrigation could result in bowel</p><p>dependence, but colonic distention is a normal physiologic stimulus to effect evacuation, and</p><p>no studies or data have indicated any adverse effects.</p><p>Colonic irrigation is also used to prevent low anterior resection syndrome in patients with a</p><p>protective stoma. (See "Low anterior resection syndrome (LARS)", section on 'Prevention'.)</p><p>PHYSICAL ACTIVITY</p><p>A common concern for many patients is the impact of the stoma on activities of daily living.</p><p>The patient can be reassured that most activities can be safely resumed with minimal, if any,</p><p>modifications. As an example, bathing and showering can be performed with the pouch on</p><p>or off, and clothing modifications are generally not required. Most sports activities can be</p><p>resumed as well, with the exception of extreme contact sports, which could potentially</p><p>https://www.uptodate.com/contents/management-of-chronic-constipation-in-adults?sectionName=Fiber&search=colostomy&topicRef=1384&anchor=H30890953&source=see_link#H30890953</p><p>https://www.uptodate.com/contents/management-of-chronic-constipation-in-adults?sectionName=Fiber&search=colostomy&topicRef=1384&anchor=H30890953&source=see_link#H30890953</p><p>https://www.uptodate.com/contents/ileostomy-or-colostomy-care-and-complications/abstract/6,11,31-33</p><p>https://www.uptodate.com/contents/low-anterior-resection-syndrome-lars?sectionName=PREVENTION&search=colostomy&topicRef=1384&anchor=H1122726640&source=see_link#H1122726640</p><p>03/03/2024, 18:05 Ileostomy or colostomy care and complications - UpToDate</p><p>https://www.uptodate.com/contents/ileostomy-or-colostomy-care-and-complications/print?search=colostomy&source=search_result&selectedTitl… 9/33</p><p>damage the stoma. The addition of a belt or binder is helpful in maintaining a pouch seal</p><p>during vigorous activity and with perspiration [6].</p><p>Sex — Sexual activity is a particular concern for many patients with an ostomy. Patient</p><p>counseling should address questions regarding sexual activity and partner response [34].</p><p>The ostomy does not affect organic sexual function. However, if the ostomy was placed due</p><p>to some form of pelvic surgery or prior radiation treatment, it is possible that the autonomic</p><p>nerves controlling sexual function, which are located adjacent the rectum and the pelvic</p><p>sidewall, may have been injured. (See "Overview of sexual dysfunction in females:</p><p>Epidemiology, risk factors, and evaluation" and "Epidemiology and etiologies of male sexual</p><p>dysfunction".)</p><p>It is helpful for the patient to empty the pouch and assure an intact pouch seal before</p><p>engaging in sexual activity. In addition, many patients and their partners find it helpful to</p><p>use lingerie or a cummerbund to conceal and secure the pouch. Commercial pouch covers,</p><p>lingerie, and undergarments specifically designed for ostomates are available.</p><p>Travel — Patients who are traveling should be advised to:</p><p>OSTOMY COMPLICATIONS</p><p>The incidence of stomal complications ranges from 14 to 79 percent [35-40]; nearly half of all</p><p>stomas eventually become "problematic" due to pouching and peristomal skin issues [13,41-</p><p>43].</p><p>Complications vary with the type of ostomy, with lower complication rates for those with end</p><p>colostomies and end ileostomies [40,44]. Loop ileostomies have the highest complication</p><p>rates [35,36,42]. The most common problems of end and loop ileostomies are dehydration</p><p>and skin irritation (related to the high-output, high alkaline enzymatic effluent) and small</p><p>bowel obstruction. Although prolapse can occur in all types of stomas, it is more prevalent in</p><p>loop colostomies, particularly those constructed using the transverse colon [40,45].</p><p>Parastomal hernia and retraction are the most common complications for end and loop</p><p>ileostomies and colostomies [40,45,46]. (See "Parastomal hernia".)</p><p>Take extra ostomy supplies, and if flying, place them in carry-on luggage.●</p><p>Some airports offer private pre-screenings upon request.●</p><p>Avoid exposing ostomy pouches and adhesive adjuncts to extreme temperatures,</p><p>which may alter the adhesive quality.</p><p>●</p><p>Drink only bottled water if local tap water is not known to be safe [14].●</p><p>https://www.uptodate.com/contents/ileostomy-or-colostomy-care-and-complications/abstract/6</p><p>https://www.uptodate.com/contents/ileostomy-or-colostomy-care-and-complications/abstract/34</p><p>https://www.uptodate.com/contents/overview-of-sexual-dysfunction-in-females-epidemiology-risk-factors-and-evaluation?search=colostomy&topicRef=1384&source=see_link</p><p>https://www.uptodate.com/contents/overview-of-sexual-dysfunction-in-females-epidemiology-risk-factors-and-evaluation?search=colostomy&topicRef=1384&source=see_link</p><p>https://www.uptodate.com/contents/epidemiology-and-etiologies-of-male-sexual-dysfunction?search=colostomy&topicRef=1384&source=see_link</p><p>https://www.uptodate.com/contents/epidemiology-and-etiologies-of-male-sexual-dysfunction?search=colostomy&topicRef=1384&source=see_link</p><p>https://www.uptodate.com/contents/ileostomy-or-colostomy-care-and-complications/abstract/35-40</p><p>https://www.uptodate.com/contents/ileostomy-or-colostomy-care-and-complications/abstract/13,41-43</p><p>https://www.uptodate.com/contents/ileostomy-or-colostomy-care-and-complications/abstract/13,41-43</p><p>https://www.uptodate.com/contents/ileostomy-or-colostomy-care-and-complications/abstract/40,44</p><p>https://www.uptodate.com/contents/ileostomy-or-colostomy-care-and-complications/abstract/35,36,42</p><p>https://www.uptodate.com/contents/ileostomy-or-colostomy-care-and-complications/abstract/40,45</p><p>https://www.uptodate.com/contents/ileostomy-or-colostomy-care-and-complications/abstract/40,45,46</p><p>https://www.uptodate.com/contents/parastomal-hernia?search=colostomy&topicRef=1384&source=see_link</p><p>https://www.uptodate.com/contents/ileostomy-or-colostomy-care-and-complications/abstract/14</p><p>03/03/2024, 18:05 Ileostomy or colostomy care and complications - UpToDate</p><p>https://www.uptodate.com/contents/ileostomy-or-colostomy-care-and-complications/print?search=colostomy&source=search_result&selectedTi… 10/33</p><p>Stomal and peristomal complications can occur in the early postoperative period or many</p><p>years following stomal construction [38-42,44,46-54]. Although profiles of early and late</p><p>ostomy complications do overlap (eg, stomas can retract early or late), they are often quite</p><p>different [13]:</p><p>Very early complications (days) — Complications that occur very early in the postoperative</p><p>course (days) are often related to technical issues [36,42] and often require return to the</p><p>operating room. Examples include large bowel obstruction due to a twist in the bowel</p><p>leading to the stoma.</p><p>Early complications (<3 months) — Early complications, defined as those occurring within</p><p>three months of stoma construction, are often related to suboptimal stoma site selection</p><p>[35,52] but are heavily influenced by patient factors (eg, old age, poor nutritional status,</p><p>higher American Society of Anesthesiologists [ASA] class, comorbidities, obesity, tobacco use,</p><p>and underlying malignancy) [13,41,42].</p><p>Early complications include stomal ischemia/necrosis, stomal bleeding, stomal retraction,</p><p>and mucocutaneous separation.</p><p>Stomal necrosis — The incidence of stomal necrosis in the immediate postoperative period</p><p>is as high as 14 percent [41,55]. Adequate mobilization of the bowel, preservation of the</p><p>blood supply to the stoma, and an adequate trephine size are important factors for avoiding</p><p>this complication. (See "Overview of surgical ostomy for fecal diversion", section on 'Ostomy</p><p>construction'.)</p><p>Independent risk factors for stomal necrosis include emergency surgery, obesity, and</p><p>inflammatory bowel disease, in particular Crohn disease [38,49].</p><p>Stomal necrosis most commonly occurs in the early postoperative period as a result of</p><p>venous congestion or arterial insufficiency (eg, tight fascial opening, excessive mesenteric</p><p>stripping). The most critical assessment is to determine the extent of necrosis, which can be</p><p>performed by inserting a lubricated test tube into the stoma and using a flashlight to</p><p>visualize the proximal mucosa. An alternative is to use a flexible sigmoidoscope or a lighted</p><p>anoscope. Management is based upon the clinical scenario:</p><p>If the necrosis extends to the proximal bowel below the anterior fascia, immediate</p><p>revision is required.</p><p>●</p><p>If the proximal bowel is viable and the necrosis is limited to the stoma (superficial to the</p><p>anterior fascia), observation may be appropriate.</p><p>●</p><p>If necrosis progresses, a revision is required.•</p><p>https://www.uptodate.com/contents/ileostomy-or-colostomy-care-and-complications/abstract/38-42,44,46-54</p><p>https://www.uptodate.com/contents/ileostomy-or-colostomy-care-and-complications/abstract/13</p><p>https://www.uptodate.com/contents/ileostomy-or-colostomy-care-and-complications/abstract/36,42</p><p>https://www.uptodate.com/contents/ileostomy-or-colostomy-care-and-complications/abstract/35,52</p><p>https://www.uptodate.com/contents/ileostomy-or-colostomy-care-and-complications/abstract/13,41,42</p><p>https://www.uptodate.com/contents/ileostomy-or-colostomy-care-and-complications/abstract/41,55</p><p>https://www.uptodate.com/contents/overview-of-surgical-ostomy-for-fecal-diversion?sectionName=OSTOMY%20CONSTRUCTION&search=colostomy&topicRef=1384&anchor=H21063025&source=see_link#H21063025</p><p>https://www.uptodate.com/contents/overview-of-surgical-ostomy-for-fecal-diversion?sectionName=OSTOMY%20CONSTRUCTION&search=colostomy&topicRef=1384&anchor=H21063025&source=see_link#H21063025</p><p>https://www.uptodate.com/contents/ileostomy-or-colostomy-care-and-complications/abstract/38,49</p><p>03/03/2024, 18:05 Ileostomy or colostomy care and complications - UpToDate</p><p>https://www.uptodate.com/contents/ileostomy-or-colostomy-care-and-complications/print?search=colostomy&source=search_result&selectedTi… 11/33</p><p>In acute settings, stoma ischemia is more often than not limited to the mucosa above the</p><p>fascia and thus can be observed, albeit with a possible resultant stricture in the future [56].</p><p>Stomal bleeding — Major bleeding from the stoma (as opposed to a gastrointestinal bleed)</p><p>is uncommon and usually indicates either a stomal laceration from a poorly fitting appliance</p><p>or the presence of peristomal varices in the patient with portal hypertension. Minor bleeding</p><p>from the stoma can also occur early in the postoperative period related to creation of the</p><p>stoma or later with overly vigorous stomal cleansing. Initial management of stomal bleeding</p><p>involves direct pressure and local cauterization (handheld cautery, silver nitrate) or suturing</p><p>of the bleeding vessel, if easily identified.</p><p>Peristomal varices are most frequently seen in patients who underwent a colectomy for</p><p>ulcerative colitis in the setting of primary sclerosing cholangitis. Peristomal varices can also</p><p>develop in patients with other causes of portal hypertension. Initial management consists of</p><p>direct pressure followed by injection sclerotherapy or direct suture. However, recurrence is</p><p>frequent, and medical therapy or intervention (eg, transjugular intrahepatic portosystemic</p><p>shunting) may be needed to reduce portal pressures [38,49]. (See "Overview of transjugular</p><p>intrahepatic portosystemic shunts (TIPS)".)</p><p>Stomal retraction — Stomal retraction is defined as a stoma that is 0.5 cm or more below</p><p>the skin surface within six weeks of construction, typically as a result of tension on the stoma</p><p>( picture 1) [35,41]. Stomal retraction leads to leakage and difficulties with pouch</p><p>adherence, resulting in peristomal skin irritation. The incidence of stomal retraction ranges</p><p>between 1 and 40 percent [35,41,42,55].</p><p>The most common risk factors are obesity, due to the thickness of the abdominal wall and</p><p>foreshortened mesentery, and initial stoma height <10 mm [42]. Proper stoma height and</p><p>minimizing tension are important factors for preventing this complication. (See "Overview of</p><p>surgical ostomy for fecal diversion", section on 'Ostomy construction'.)</p><p>Management also depends upon the clinical scenario:</p><p>If sloughing occurs, only gentle debridement may be necessary. Sloughing of the</p><p>stoma can result in stomal retraction and pouching challenges but may not require</p><p>surgical intervention.</p><p>•</p><p>If the stoma retracts below the fascia, immediate operative revision is required to</p><p>prevent intra-abdominal contamination from the stoma output [13].</p><p>●</p><p>A stoma that has retracted but stays above the fascia can be managed with local wound</p><p>care, a convex pouching system, and the use of a belt or binder. If these measures fail</p><p>to provide a secure pouch seal, surgical revision may be needed. However, revision is</p><p>appropriate only when an improved outcome can be expected and is not appropriate</p><p>●</p><p>https://www.uptodate.com/contents/ileostomy-or-colostomy-care-and-complications/abstract/56</p><p>https://www.uptodate.com/contents/silver-nitrate-drug-information?search=colostomy&topicRef=1384&source=see_link</p><p>https://www.uptodate.com/contents/ileostomy-or-colostomy-care-and-complications/abstract/38,49</p><p>https://www.uptodate.com/contents/overview-of-transjugular-intrahepatic-portosystemic-shunts-tips?search=colostomy&topicRef=1384&source=see_link</p><p>https://www.uptodate.com/contents/overview-of-transjugular-intrahepatic-portosystemic-shunts-tips?search=colostomy&topicRef=1384&source=see_link</p><p>https://www.uptodate.com/contents/image?imageKey=GAST%2F81992&topicKey=SURG%2F1384&search=colostomy&rank=1%7E101&source=see_link</p><p>https://www.uptodate.com/contents/image?imageKey=GAST%2F81992&topicKey=SURG%2F1384&search=colostomy&rank=1%7E101&source=see_link</p><p>https://www.uptodate.com/contents/ileostomy-or-colostomy-care-and-complications/abstract/35,41</p><p>https://www.uptodate.com/contents/ileostomy-or-colostomy-care-and-complications/abstract/35,41,42,55</p><p>https://www.uptodate.com/contents/ileostomy-or-colostomy-care-and-complications/abstract/42</p><p>https://www.uptodate.com/contents/overview-of-surgical-ostomy-for-fecal-diversion?sectionName=OSTOMY%20CONSTRUCTION&search=colostomy&topicRef=1384&anchor=H21063025&source=see_link#H21063025</p><p>https://www.uptodate.com/contents/overview-of-surgical-ostomy-for-fecal-diversion?sectionName=OSTOMY%20CONSTRUCTION&search=colostomy&topicRef=1384&anchor=H21063025&source=see_link#H21063025</p><p>https://www.uptodate.com/contents/ileostomy-or-colostomy-care-and-complications/abstract/13</p><p>03/03/2024, 18:05 Ileostomy or colostomy care and complications - UpToDate</p><p>https://www.uptodate.com/contents/ileostomy-or-colostomy-care-and-complications/print?search=colostomy&source=search_result&selectedTi… 12/33</p><p>Mucocutaneous separation — Mucocutaneous separation refers to the separation of the</p><p>ostomy from the peristomal skin. Mucocutaneous separation results in leakage and skin</p><p>irritation. It occurs in 12 to 24 percent of patients early in the postoperative period [41,42].</p><p>The best approach to preventing this complication is meticulous technique when</p><p>approximating the bowel to the skin. (See "Overview of surgical ostomy for fecal diversion",</p><p>section on 'Ostomy construction and maturation'.)</p><p>Mucocutaneous separation can be partial or circumferential; if circumferential, stomal</p><p>stenosis can occur as the tissues heal by secondary intention. (See 'Stomal stenosis' below.)</p><p>Circumferential separation of the suture line with retraction of the stoma should be revised</p><p>immediately. For less severe separations, the defect can be filled with absorptive material,</p><p>such as calcium alginate, skin barrier powder, paste, or hydrofiber. Covering the area with</p><p>the skin protective barrier with a barrier ring will help protect the wound from effluent and</p><p>facilitate healing.</p><p>Late complications (>3 months) — Late stomal complications are generally described for</p><p>permanent ostomies since many temporary stomas are reversed within three months [6].</p><p>Risk factors for late complications include duration of stoma, increases in intra-abdominal</p><p>pressure (obesity, chronic obstructive pulmonary disease), emergency surgery [41,42,55],</p><p>inadequate mobilization of the bowel with resultant height of stoma <10 mm, and</p><p>inappropriately sized aperture [13,41].</p><p>The most common late complications include parastomal hernia, stomal prolapse, and</p><p>stoma stenosis [35]. A closed stoma site following ostomy reversal can also be associated</p><p>with complications such as wound infection, delayed healing, and hernia formation.</p><p>Parastomal hernia — Parastomal hernia formation is a common complication, especially</p><p>among colostomy patients. Risk factors include obesity and poor abdominal muscle tone,</p><p>conditions producing a chronic cough, placement of the stoma outside of the rectus muscle,</p><p>and a large fascial opening. (See "Parastomal hernia", section on 'Risk factors'.)</p><p>Most parastomal hernias are asymptomatic and do not progress to complications (eg,</p><p>incarceration, strangulation, bowel obstruction) [58]. The diagnosis and management of</p><p>when the cause of the problem has not been addressed [57,58]. Approximately 1</p><p>percent of patients experience stomal retraction as a result of postoperative weight</p><p>gain. Overweight patients should be encouraged and assisted to lose weight prior to</p><p>surgical revision.</p><p>If nonoperative management of a retracted stoma fails, operative revision or re-siting</p><p>of the stoma is necessary. Re-siting the stoma to the upper abdominal wall, which is</p><p>usually thinner, may be helpful.</p><p>●</p><p>https://www.uptodate.com/contents/ileostomy-or-colostomy-care-and-complications/abstract/41,42</p><p>https://www.uptodate.com/contents/overview-of-surgical-ostomy-for-fecal-diversion?sectionName=Ostomy%20construction%20and%20maturation&search=colostomy&topicRef=1384&anchor=H60239606&source=see_link#H60239606</p><p>https://www.uptodate.com/contents/overview-of-surgical-ostomy-for-fecal-diversion?sectionName=Ostomy%20construction%20and%20maturation&search=colostomy&topicRef=1384&anchor=H60239606&source=see_link#H60239606</p><p>https://www.uptodate.com/contents/ileostomy-or-colostomy-care-and-complications/abstract/6</p><p>https://www.uptodate.com/contents/ileostomy-or-colostomy-care-and-complications/abstract/41,42,55</p><p>https://www.uptodate.com/contents/ileostomy-or-colostomy-care-and-complications/abstract/13,41</p><p>https://www.uptodate.com/contents/ileostomy-or-colostomy-care-and-complications/abstract/35</p><p>https://www.uptodate.com/contents/parastomal-hernia?sectionName=Risk%20factors&search=colostomy&topicRef=1384&anchor=H617250177&source=see_link#H617250177</p><p>https://www.uptodate.com/contents/ileostomy-or-colostomy-care-and-complications/abstract/58</p><p>https://www.uptodate.com/contents/ileostomy-or-colostomy-care-and-complications/abstract/57,58</p><p>03/03/2024, 18:05 Ileostomy or colostomy care and complications - UpToDate</p><p>https://www.uptodate.com/contents/ileostomy-or-colostomy-care-and-complications/print?search=colostomy&source=search_result&selectedTi… 13/33</p><p>parastomal hernia is discussed separately. (See "Parastomal hernia", section on 'Indications</p><p>for hernia repair' and "Parastomal hernia", section on 'Surgical techniques'.)</p><p>Stomal prolapse — Prolapse is the telescoping of the intestine out from the stoma and can</p><p>occur with any type of stoma. Prolapse can make appliance placement and adherence</p><p>difficult, and prolonged prolapse causes intestinal edema and, if significant, can lead to</p><p>intestinal incarceration or strangulation.</p><p>The incidence of prolapse with an ileostomy is 2 to 3 percent, whereas the incidence for</p><p>prolapse with a colostomy is 2 to 10 percent. Transverse loop colostomies have the highest</p><p>incidence of prolapse at up to 30 percent [38,49]. Risk factors for prolapse may include a</p><p>large abdominal trephine, increased intra-abdominal pressure, and a redundant loop of</p><p>bowel proximal to the stoma [35]. Alternative fixation techniques during ostomy construction</p><p>have been proposed to prevent prolapse [38,44,49,59]. However, there are no data to</p><p>support these approaches. (See "Overview of surgical ostomy for fecal diversion", section on</p><p>'Other sites of fixation'.)</p><p>Uncomplicated prolapse can be managed conservatively with cool compresses and/or</p><p>application of an osmotic agent (eg, table sugar or honey) to reduce edema, followed by</p><p>manual reduction of the prolapse and application of a binder with a prolapse over-belt to</p><p>keep the bowel recued into the abdomen, or by pouching modifications to accommodate the</p><p>prolapsed bowel when reduction cannot be established or maintained [28,60]. Manual</p><p>reduction should be initiated at the very tip of the prolapse (beehive) or lumen, and then</p><p>gentle, slow invagination should proceed. In this way, the prolapsed bowel will intussuscept</p><p>back into the abdomen.</p><p>Complicated prolapse or prolapse producing ischemic changes or severe mucosal irritation</p><p>and bleeding usually requires surgical intervention. Local revision of the prolapse is</p><p>accomplished by performing a full-thickness resection of the prolapsed intestinal segment</p><p>with construction of the stoma at the original site. In the event of a further recurrence,</p><p>additional bowel resection and relocation of the stoma may be necessary [35].</p><p>Stomal stenosis — Stomal stenosis refers to a narrowing of the stoma sufficient to</p><p>interfere with normal function. The incidence ranges from 2 to 15 percent and is more</p><p>common with an end colostomy [35,61,62].</p><p>Stomal stenosis can occur in the early postoperative period but is more likely to develop</p><p>months later. Early stenosis of ileostomy, due to edema at the fascial and more superficial</p><p>levels (assuming appropriate skin opening), can be conservatively managed with gentle</p><p>insertion of a large, 36 French soft-tipped Foley bladder catheter just proximal to the fascial</p><p>level. The balloon should not be inflated. If there is significant resistance upon intubation of</p><p>the stoma, the procedure should be abandoned. Care must be taken to avoid perforation.</p><p>https://www.uptodate.com/contents/parastomal-hernia?sectionName=Indications%20for%20hernia%20repair&search=colostomy&topicRef=1384&anchor=H21353317&source=see_link#H21353317</p><p>https://www.uptodate.com/contents/parastomal-hernia?sectionName=Indications%20for%20hernia%20repair&search=colostomy&topicRef=1384&anchor=H21353317&source=see_link#H21353317</p><p>https://www.uptodate.com/contents/parastomal-hernia?sectionName=SURGICAL%20TECHNIQUES&search=colostomy&topicRef=1384&anchor=H617284133&source=see_link#H617284133</p><p>https://www.uptodate.com/contents/ileostomy-or-colostomy-care-and-complications/abstract/38,49</p><p>https://www.uptodate.com/contents/ileostomy-or-colostomy-care-and-complications/abstract/35</p><p>https://www.uptodate.com/contents/ileostomy-or-colostomy-care-and-complications/abstract/38,44,49,59</p><p>https://www.uptodate.com/contents/overview-of-surgical-ostomy-for-fecal-diversion?sectionName=Other%20sites%20of%20fixation&search=colostomy&topicRef=1384&anchor=H60240936&source=see_link#H60240936</p><p>https://www.uptodate.com/contents/overview-of-surgical-ostomy-for-fecal-diversion?sectionName=Other%20sites%20of%20fixation&search=colostomy&topicRef=1384&anchor=H60240936&source=see_link#H60240936</p><p>https://www.uptodate.com/contents/ileostomy-or-colostomy-care-and-complications/abstract/28,60</p><p>https://www.uptodate.com/contents/ileostomy-or-colostomy-care-and-complications/abstract/35</p><p>https://www.uptodate.com/contents/ileostomy-or-colostomy-care-and-complications/abstract/35,61,62</p><p>03/03/2024, 18:05 Ileostomy or colostomy care and complications - UpToDate</p><p>https://www.uptodate.com/contents/ileostomy-or-colostomy-care-and-complications/print?search=colostomy&source=search_result&selectedTi… 14/33</p><p>Stenosis can occur later at the skin or the fascia level or stoma outlet secondary due to</p><p>scarring or tightness of the mucocutaneous junction. Stenosis may be attributable to</p><p>peristomal sepsis, retraction, an ill-fitting pouching system, or suboptimal surgical</p><p>technique. The patient should be evaluated for other processes that could contribute (eg,</p><p>Crohn disease, primary or recurrent malignancy).</p><p>Mild stenosis may be identified only by digital examination of the stoma, with few symptoms,</p><p>and can usually be managed by dietary modifications (eg, avoidance of insoluble fiber);</p><p>gentle routine dilatation of the stoma may also be helpful but is not evidence based.</p><p>Clinically significant stenosis usually causes cramping pain followed by explosive output and</p><p>usually requires surgical correction [38]. For these, local revision may be preferred over</p><p>dilation, which can be complicated by peristomal bleeding, tissue injury, fibrosis, and further</p><p>stenosis. Local repair involves excision of scar tissue with adequate mobilization and creation</p><p>of a new tension-free stoma at a new or relocated site. Enlargement of the skin opening via a</p><p>double Z-plasty technique may be useful in some situations (eg, limited number of sites for</p><p>ostomy relocation, limited scarring) [63].</p><p>Peristomal skin problems (any time) — The most common ostomy complication is</p><p>peristomal skin breakdown, with varying severities from minor skin trauma, to dermatitis, to</p><p>ulceration, to pyoderma gangrenosum (in Crohn patients). Peristomal skin breakdown can</p><p>occur early or late and is more prevalent with ileostomies than colostomies.</p><p>Mechanical trauma — Mechanical trauma typically presents as patchy areas of irritated,</p><p>denuded skin that result from repeated removal of adhesive products or overly aggressive</p><p>cleansing techniques.</p><p>Patients with peristomal hair should be taught to clip the hair to prevent mechanical trauma</p><p>to the hair follicles. Patients should be taught to use plasticizing skin sealants to help prevent</p><p>skin damage (skin sealants are optional and specific to manufacturer) with pouch removal</p><p>and should be cautioned to use a gentle technique when cleaning the peristomal skin. (See</p><p>'Pouch systems and routine ostomy care' above.)</p><p>Treatment involves elimination of the causative factors and application of skin barrier</p><p>powder to the involved areas, followed by blotting with a skin sealant or moistened finger to</p><p>provide a nonpowdery pouching surface [6].</p><p>Dermatitis — Peristomal skin irritation is more common for patients with an ileostomy due</p><p>to the nature of the effluent ( picture 2). It is characterized by severely denuded skin along</p><p>the inferior aspect of the stoma. Creating a protuberant spout for the ileostomy</p><p>approximately 2 to 3 cm high to optimize pouch fit is the best method to minimize contact of</p><p>effluent with the skin [2]. (See "Overview of surgical ostomy for fecal diversion", section on</p><p>'Ostomy construction and maturation'.)</p><p>https://www.uptodate.com/contents/ileostomy-or-colostomy-care-and-complications/abstract/38</p><p>https://www.uptodate.com/contents/ileostomy-or-colostomy-care-and-complications/abstract/63</p><p>https://www.uptodate.com/contents/ileostomy-or-colostomy-care-and-complications/abstract/6</p><p>https://www.uptodate.com/contents/image?imageKey=GAST%2F81549&topicKey=SURG%2F1384&search=colostomy&rank=1%7E101&source=see_link</p><p>https://www.uptodate.com/contents/image?imageKey=GAST%2F81549&topicKey=SURG%2F1384&search=colostomy&rank=1%7E101&source=see_link</p><p>https://www.uptodate.com/contents/ileostomy-or-colostomy-care-and-complications/abstract/2</p><p>https://www.uptodate.com/contents/overview-of-surgical-ostomy-for-fecal-diversion?sectionName=Ostomy%20construction%20and%20maturation&search=colostomy&topicRef=1384&anchor=H60239606&source=see_link#H60239606</p><p>https://www.uptodate.com/contents/overview-of-surgical-ostomy-for-fecal-diversion?sectionName=Ostomy%20construction%20and%20maturation&search=colostomy&topicRef=1384&anchor=H60239606&source=see_link#H60239606</p><p>03/03/2024, 18:05 Ileostomy or colostomy care and complications - UpToDate</p><p>https://www.uptodate.com/contents/ileostomy-or-colostomy-care-and-complications/print?search=colostomy&source=search_result&selectedTi… 15/33</p><p>Peristomal skin irritation can also result from mechanical trauma, an allergic reaction to a</p><p>pouching product, or peristomal fungal infection, which is more common in warm and</p><p>humid climates or related to antibiotic therapy [35]. Fungal infections present as a</p><p>maculopapular rash with distinct satellite lesions ( picture 3).</p><p>Allergic reactions can occur with any of the products used to protect the peristomal skin or to</p><p>assure adhesion of the pouching system; allergic reactions are characterized by pruritus,</p><p>erythema, and blistering in the area corresponding to and demarcated by contact with the</p><p>offending agent ( picture 4).</p><p>Treatment involves identification and correction of the causative factors, elimination of any</p><p>allergens, and treatment of the denuded areas with skin barrier powder or antifungal</p><p>powder (eg, nystatin or miconazole). If necessary, the powder can be lightly blotted with a</p><p>moist finger or skin sealant to assure a pouchable surface [14,57,58,64]. Topical steroids may</p><p>sometimes be required for a severe reaction [14,57,58].</p><p>Whenever possible, the patient with peristomal skin problems should be seen by an ostomy</p><p>nurse specialist. Refractory peristomal skin breakdown should prompt a referral to a surgeon</p><p>with experience and expertise in stoma management. As an example, for patients who</p><p>experience weight or body habitus changes after the stoma is created, fat grafting, focus</p><p>liposuction, scar release, or excision of redundant skin by a plastic surgeon may help with</p><p>pouching and alleviate peristomal skin problems [65].</p><p>Parastomal ulceration — Parastomal</p><p>ulceration, defined as discontinuity of peristomal</p><p>skin with adjacent inflammation, is usually the result of an infected postoperative hematoma</p><p>or intestinal fistula [35].</p><p>Granulomas — Granulomas are red, moist, elevated lesions at the mucocutaneous border.</p><p>Often, they are a result of retained suture or other extraneous material. Granulomas bleed</p><p>easily and may be tender. They may become infected. Maintaining barrier seals can be a</p><p>problem. Treatment consists of examining and removing any extraneous material and</p><p>eliminating the lesion. Silver nitrate should be applied to remove the elevated tissue. Several</p><p>treatments may be necessary. After treatment and until healed, the area should be crusted</p><p>with barrier powder and a skin sealant. If extensive, the pouching system may need to be</p><p>adjusted until the area heals. Failure of lesions to heal or frequent reoccurrence should be</p><p>evaluated for other pathology [66].</p><p>Peristomal pyoderma gangrenosum — Pyoderma gangrenosum (PG) is a neutrophilic</p><p>dermatosis with unclear etiology. Peristomal pyoderma gangrenosum (PPG) is a subtype of</p><p>PG that occurs at the stoma site typically in patients with inflammatory bowel disease (IBD)</p><p>[67]. PPG occurs in 0.5 to 1.5 per million people annually, which accounts for 15 percent of</p><p>https://www.uptodate.com/contents/ileostomy-or-colostomy-care-and-complications/abstract/35</p><p>https://www.uptodate.com/contents/image?imageKey=GAST%2F79045&topicKey=SURG%2F1384&search=colostomy&rank=1%7E101&source=see_link</p><p>https://www.uptodate.com/contents/image?imageKey=GAST%2F79045&topicKey=SURG%2F1384&search=colostomy&rank=1%7E101&source=see_link</p><p>https://www.uptodate.com/contents/image?imageKey=GAST%2F68947&topicKey=SURG%2F1384&search=colostomy&rank=1%7E101&source=see_link</p><p>https://www.uptodate.com/contents/image?imageKey=GAST%2F68947&topicKey=SURG%2F1384&search=colostomy&rank=1%7E101&source=see_link</p><p>https://www.uptodate.com/contents/nystatin-drug-information?search=colostomy&topicRef=1384&source=see_link</p><p>https://www.uptodate.com/contents/miconazole-drug-information?search=colostomy&topicRef=1384&source=see_link</p><p>https://www.uptodate.com/contents/ileostomy-or-colostomy-care-and-complications/abstract/14,57,58,64</p><p>https://www.uptodate.com/contents/ileostomy-or-colostomy-care-and-complications/abstract/14,57,58</p><p>https://www.uptodate.com/contents/ileostomy-or-colostomy-care-and-complications/abstract/65</p><p>https://www.uptodate.com/contents/ileostomy-or-colostomy-care-and-complications/abstract/35</p><p>https://www.uptodate.com/contents/silver-nitrate-drug-information?search=colostomy&topicRef=1384&source=see_link</p><p>https://www.uptodate.com/contents/ileostomy-or-colostomy-care-and-complications/abstract/66</p><p>https://www.uptodate.com/contents/ileostomy-or-colostomy-care-and-complications/abstract/67</p><p>03/03/2024, 18:05 Ileostomy or colostomy care and complications - UpToDate</p><p>https://www.uptodate.com/contents/ileostomy-or-colostomy-care-and-complications/print?search=colostomy&source=search_result&selectedTi… 16/33</p><p>PG cases [68]. (See "Pyoderma gangrenosum: Pathogenesis, clinical features, and diagnosis"</p><p>and "Dermatologic and ocular manifestations of inflammatory bowel disease".)</p><p>According to a 2019 systematic review (79 studies; 335 cases), most PPG patients are female</p><p>(67 percent), with a mean age of 48 years and a diagnosis of IBD (81 percent; Crohn disease</p><p>50 percent, ulcerative colitis 31 percent) [68]. PPG has also been identified in patients with</p><p>intra-abdominal malignancies [69]. Ileostomies, colostomies, and other stomas (urostomies)</p><p>are involved in 78, 16, and 6 percent of patients.</p><p>PPG can develop within weeks to years after stoma construction, with an incidence of <1</p><p>percent of stomas (2 to 4 percent in those with IBD) [68-72]. Sixty-nine percent of patients</p><p>reported an IBD flare with the onset of PPG [68]. The lesions typically present as full-</p><p>thickness ulcers, and pain and pathergy are dominant characteristics ( picture 5).</p><p>The diagnosis of PPG is clinical and usually one of exclusion since there is no definitive</p><p>diagnostic test. The lesion is frequently misdiagnosed as a stitch abscess, contact dermatitis,</p><p>urinary or fecal fistula, an extension of Crohn disease, or a wound infection. Patients with</p><p>suspected PPG should be referred to a dermatologist for possible biopsy.</p><p>Biopsy of the skin lesion is nondiagnostic but does help to exclude certain pathologies (eg,</p><p>cancer, Crohn disease) [69]. If a skin biopsy is performed to rule out other pathology, acute</p><p>and chronic inflammation is the typical finding. The biopsy should be performed with caution</p><p>as this may increase the size of the wound. Granulomas may be noted on microscopic</p><p>examination. Biopsies should be performed at the leading edge of the ulceration with 4 to 6</p><p>mm punch biopsies. Similarly, cultures should also be obtained to evaluate for any infectious</p><p>etiologies; PPG ulcers are sterile or grow commensal skin or gut flora.</p><p>Selecting an unaffected segment of bowel for the stoma is the best way to prevent this</p><p>complication. However, once occurring, these lesions are managed by systemic, intralesional,</p><p>and/or topical anti-inflammatory agents, depending on severity [68] (see "Pyoderma</p><p>gangrenosum: Treatment and prognosis"):</p><p>Mild cases of PPG without active systemic disease can be managed with topical agents.</p><p>Topical therapies for PPG include corticosteroids and calcineurin inhibitors (eg,</p><p>tacrolimus) with similar clinical efficacies (62 versus 56 percent). Intralesional injection</p><p>of corticosteroids is less effective and, in some cases, worsened PPG.</p><p>●</p><p>More severe or rapidly evolving cases of PPG require systemic medication or even</p><p>surgical intervention. Corticosteroids are the most commonly used systemic treatment,</p><p>with a complete response rate of 52 percent in 146 patients. Other systemic options</p><p>with a similar (50 percent) response rate include cyclosporine and dapsone. Systemic</p><p>metronidazole, azathioprine, sulfasalazine, and tacrolimus are less commonly used.</p><p>Tumor necrosis factor alpha inhibitors such as infliximab and adalimumab are favorable</p><p>●</p><p>https://www.uptodate.com/contents/ileostomy-or-colostomy-care-and-complications/abstract/68</p><p>https://www.uptodate.com/contents/pyoderma-gangrenosum-pathogenesis-clinical-features-and-diagnosis?search=colostomy&topicRef=1384&source=see_link</p><p>https://www.uptodate.com/contents/dermatologic-and-ocular-manifestations-of-inflammatory-bowel-disease?search=colostomy&topicRef=1384&source=see_link</p><p>https://www.uptodate.com/contents/ileostomy-or-colostomy-care-and-complications/abstract/68</p><p>https://www.uptodate.com/contents/ileostomy-or-colostomy-care-and-complications/abstract/69</p><p>https://www.uptodate.com/contents/ileostomy-or-colostomy-care-and-complications/abstract/68-72</p><p>https://www.uptodate.com/contents/ileostomy-or-colostomy-care-and-complications/abstract/68</p><p>https://www.uptodate.com/contents/image?imageKey=GAST%2F72285&topicKey=SURG%2F1384&search=colostomy&rank=1%7E101&source=see_link</p><p>https://www.uptodate.com/contents/image?imageKey=GAST%2F72285&topicKey=SURG%2F1384&search=colostomy&rank=1%7E101&source=see_link</p><p>https://www.uptodate.com/contents/ileostomy-or-colostomy-care-and-complications/abstract/69</p><p>https://www.uptodate.com/contents/ileostomy-or-colostomy-care-and-complications/abstract/68</p><p>https://www.uptodate.com/contents/pyoderma-gangrenosum-treatment-and-prognosis?search=colostomy&topicRef=1384&source=see_link</p><p>https://www.uptodate.com/contents/pyoderma-gangrenosum-treatment-and-prognosis?search=colostomy&topicRef=1384&source=see_link</p><p>https://www.uptodate.com/contents/tacrolimus-drug-information?search=colostomy&topicRef=1384&source=see_link</p><p>https://www.uptodate.com/contents/cyclosporine-ciclosporin-drug-information?search=colostomy&topicRef=1384&source=see_link</p><p>https://www.uptodate.com/contents/dapsone-drug-information?search=colostomy&topicRef=1384&source=see_link</p><p>https://www.uptodate.com/contents/metronidazole-drug-information?search=colostomy&topicRef=1384&source=see_link</p><p>https://www.uptodate.com/contents/azathioprine-drug-information?search=colostomy&topicRef=1384&source=see_link</p><p>https://www.uptodate.com/contents/sulfasalazine-drug-information?search=colostomy&topicRef=1384&source=see_link</p><p>https://www.uptodate.com/contents/tacrolimus-drug-information?search=colostomy&topicRef=1384&source=see_link</p><p>https://www.uptodate.com/contents/infliximab-including-biosimilars-drug-information?search=colostomy&topicRef=1384&source=see_link</p><p>https://www.uptodate.com/contents/adalimumab-including-biosimilars-drug-information?search=colostomy&topicRef=1384&source=see_link</p><p>03/03/2024, 18:05 Ileostomy or colostomy care and complications - UpToDate</p><p>https://www.uptodate.com/contents/ileostomy-or-colostomy-care-and-complications/print?search=colostomy&source=search_result&selectedTi… 17/33</p><p>Wound care is critical for PPG management. The overall goals are to provide a clean wound</p><p>environment, absorb exudate, maintain moisture, and prevent further skin damage [73].</p><p>Care must be taken to minimize trauma since pathergy is a prominent feature of these</p><p>lesions. Dressings should be nonadherent, and stoma management should be modified to</p><p>minimize trauma to the affected area [58,74].</p><p>Surgical management may be required for intractability (most common), severe colitis, or</p><p>complications (eg, perforation, stenosis, obstruction, herniation). The success rate depends</p><p>on surgical technique [68]:</p><p>Continent ileostomy complications</p><p>Nipple valve slippage — Patients with a Kock pouch or Barnett continent ileostomy</p><p>reservoir can develop nipple valve slippage, which presents as obstruction or inability to</p><p>appropriately intubate and evacuate intestinal contents. (See "Overview of surgical ostomy</p><p>for fecal diversion", section on 'Continent ileostomy'.)</p><p>Surgical management is indicated. Revision may be possible; however, some situations</p><p>require a resection and reconstruction of a new continent-type ileostomy or end-ileostomy.</p><p>SOCIETY GUIDELINE LINKS</p><p>Links to society and government-sponsored guidelines from selected countries and regions</p><p>around the world are provided separately. (See "Society guideline links: Parastomal hernia".)</p><p>INFORMATION FOR PATIENTS</p><p>UpToDate offers two types of patient education materials, "The Basics" and "Beyond the</p><p>Basics." The Basics patient education pieces are written in plain language, at the 5 to 6</p><p>grade reading level, and they answer the four or five key questions a patient might have</p><p>therapeutic options for PPG concomitant with active IBD and can be used for refractory</p><p>PPG regardless of whether IBD is present.</p><p>Stoma closure or resection of bowel with active IBD completely healed PPG with few</p><p>recurrences in small case series.</p><p>●</p><p>Stoma relocation resolved PPG in almost all patients, but 67 percent recurred at the</p><p>new stoma location.</p><p>●</p><p>Wound debridement was less effective, associated with only 26 percent complete</p><p>response.</p><p>●</p><p>th th</p><p>https://www.uptodate.com/contents/ileostomy-or-colostomy-care-and-complications/abstract/73</p><p>https://www.uptodate.com/contents/ileostomy-or-colostomy-care-and-complications/abstract/58,74</p><p>https://www.uptodate.com/contents/ileostomy-or-colostomy-care-and-complications/abstract/68</p><p>https://www.uptodate.com/contents/overview-of-surgical-ostomy-for-fecal-diversion?sectionName=Continent%20ileostomy&search=colostomy&topicRef=1384&anchor=H314988881&source=see_link#H314988881</p><p>https://www.uptodate.com/contents/overview-of-surgical-ostomy-for-fecal-diversion?sectionName=Continent%20ileostomy&search=colostomy&topicRef=1384&anchor=H314988881&source=see_link#H314988881</p><p>https://www.uptodate.com/contents/society-guideline-links-parastomal-hernia?search=colostomy&topicRef=1384&source=see_link</p><p>03/03/2024, 18:05 Ileostomy or colostomy care and complications - UpToDate</p><p>https://www.uptodate.com/contents/ileostomy-or-colostomy-care-and-complications/print?search=colostomy&source=search_result&selectedTi… 18/33</p><p>about a given condition. These articles are best for patients who want a general overview</p><p>and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are</p><p>longer, more sophisticated, and more detailed. These articles are written at the 10 to 12</p><p>grade reading level and are best for patients who want in-depth information and are</p><p>comfortable with some medical jargon.</p><p>Here are the patient education articles that are relevant to this topic. We encourage you to</p><p>print or e-mail these topics to your patients. (You can also locate patient education articles</p><p>on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)</p><p>SUMMARY AND RECOMMENDATIONS</p><p>th th</p><p>Basics topics (see "Patient education: Living with a colostomy (The Basics)" and "Patient</p><p>education: Colectomy (The Basics)" and "Patient education: Living with an ileostomy</p><p>(The Basics)")</p><p>●</p><p>Forms of fecal diversion – Fecal diversions may be required on either a temporary or</p><p>permanent basis. Fecal diversions are commonly classified according to the segment of</p><p>the bowel used (eg, colon, small bowel) and/or surgical construction (eg, loop, end).</p><p>Location and construction have an impact on routine management and the frequency</p><p>and types of complications. (See 'Introduction' above and "Overview of surgical ostomy</p><p>for fecal diversion", section on 'Fecal diversions'.)</p><p>●</p><p>Patient education – Patients with a colostomy or an ileostomy must adapt to a</p><p>significant alteration in body image as well as challenges related to odor and gas</p><p>management, sexual activity, traveling, and dietary limitations. A nurse who specializes</p><p>in the management of ostomies (eg, enterostomal therapy nurse, wound ostomy</p><p>continence nurse) can provide advice to the patient regarding the daily management of</p><p>an ostomy as well as fit the patient with an appropriately sized pouch system. The</p><p>patient can be reassured that most activities, including daily living, sex, sports, and</p><p>travel, can be safely resumed with minimal, if any, modifications. (See 'Patient</p><p>education' above and 'Pouch systems and routine ostomy care' above and 'Physical</p><p>activity' above.)</p><p>●</p><p>Managing gas – Specific foods can influence the amount of the gas and the</p><p>consistency and odor of the effluent ( table 1). Dietary modifications and over-the-</p><p>counter gas-reducing agents (eg, Beano and Gas-X) help reduce the volume of gas.</p><p>Other strategies to control gas include "muffling" measures, "venting" strategies, and</p><p>measures that affect the "timing" of flatulence. The usual "lag time" between ingestion</p><p>of a gas-producing food and actual flatulence is between two and four hours for</p><p>●</p><p>https://www.uptodate.com/contents/living-with-a-colostomy-the-basics?search=colostomy&topicRef=1384&source=see_link</p><p>https://www.uptodate.com/contents/colectomy-the-basics?search=colostomy&topicRef=1384&source=see_link</p><p>https://www.uptodate.com/contents/colectomy-the-basics?search=colostomy&topicRef=1384&source=see_link</p><p>https://www.uptodate.com/contents/living-with-an-ileostomy-the-basics?search=colostomy&topicRef=1384&source=see_link</p><p>https://www.uptodate.com/contents/living-with-an-ileostomy-the-basics?search=colostomy&topicRef=1384&source=see_link</p><p>https://www.uptodate.com/contents/overview-of-surgical-ostomy-for-fecal-diversion?sectionName=FECAL%20DIVERSIONS&search=colostomy&topicRef=1384&anchor=H60234724&source=see_link#H60234724</p><p>https://www.uptodate.com/contents/overview-of-surgical-ostomy-for-fecal-diversion?sectionName=FECAL%20DIVERSIONS&search=colostomy&topicRef=1384&anchor=H60234724&source=see_link#H60234724</p><p>https://www.uptodate.com/contents/image?imageKey=GAST%2F64218&topicKey=SURG%2F1384&search=colostomy&rank=1%7E101&source=see_link</p><p>https://www.uptodate.com/contents/image?imageKey=GAST%2F64218&topicKey=SURG%2F1384&search=colostomy&rank=1%7E101&source=see_link</p><p>https://www.uptodate.com/contents/beano-alpha-galactosidase-drug-information?search=colostomy&topicRef=1384&source=see_link</p><p>03/03/2024, 18:05 Ileostomy or colostomy care and complications - UpToDate</p><p>https://www.uptodate.com/contents/ileostomy-or-colostomy-care-and-complications/print?search=colostomy&source=search_result&selectedTi… 19/33</p><p>ileostomy and six to eight hours for distal colostomy.</p>