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Colostomy care, as the name suggests, is an all-encompassing term referring to colostomy management, from its creation to peristomal skin management, to colostomy appliance application and mental health management while dealing with a colostomy. The purpose of colostomy care is for skin protection and care for patient acceptance and to prevent stoma related complications. This activity outlines colostomy creation and care and highlights the role of the interprofessional team in evaluating and treating patients with this condition. Objectives: Identify the indications for colostomy and the different types of colostomies. Explain the importance of colostomy care and the steps in colostomy care. Summarize the risks associated with a colostomy. Explain the importance of improving care coordination among the interprofessional team to enhance the delivery of care for patients with a colostomy. Access free multiple choice questions on this topic.

A stoma is the exteriorization of a loop of bowel from the anterior abdominal wall, done during a surgical procedure. It is done for diversion or decompression of the remaining bowel. A colostomy is a type of stoma in which the colon (ascending/transverse/descending/sigmoid) is exteriorized. This may be done to treat disease or to relieve an obstruction or to prevent the remaining bowel from contamination by fecal matter. It may be temporary or permanent, depending on the indication for which it was performed. Most stomas are incontinent, which means that there is no voluntary control over the passage of flatus and feces from the stoma. This makes colostomy care a mandatory procedure after colostomy creation. Colostomy care, as the name suggests, is an all-encompassing term referring to colostomy management, from its creation to peristomal skin management, to colostomy appliance application and mental health management while dealing with a colostomy. The purpose of colostomy care is for skin protection and care for patient acceptance and to prevent stoma related complications.[1][2]

Providers and nurses should monitor stomas at regular intervals to look for the multiple complications of colostomies as an integrated team approach. Some complications are extremely troublesome to patients, and they come to the hospital with these presentations, but others may be more occult and have to be looked for. Minor troublesome complaints of the patient include offensive smell, the repeated requirement of draining the colostomy appliance, or repeated colostomy bag leakage. Offensive smells can be managed by stomal deodorants or deodorized colostomy bags or avoidance of food like fish, eggs, or onions that release such odors. Repeated bag leakage can be prevented by preoperative stoma site marking and reassurance and counseling in the postoperative period. Moderately severe complaints include pain and skin excoriation around the stomal site, stomal diarrhea, or constipation or requirement for colostomy irrigation or enemas. Pain and skin excoriation may be managed by application of creams around the stomal site, with the application of the right size of the cut end on the back of the baseplate to be not more than 1/16 to 1/8 larger than the diameter of the stoma to prevent contact of fecal matter with the peri-stomal skin. Regular change of stomal appliances should be done, with the removal of the older bag with gentle pressure on the skin towards the abdomen and not with the severe force pulling the colostomy bag.

Moderately severe complaints include pain and skin excoriation around the stomal site, stomal diarrhea, or constipation or requirement for colostomy irrigation or enemas. Pain and skin excoriation may be managed by application of creams around the stomal site, with the application of the right size of the cut end on the back of the baseplate to be not more than 1/16 to 1/8 larger than the diameter of the stoma to prevent contact of fecal matter with the peri-stomal skin. Regular change of stomal appliances should be done, with the removal of the older bag with gentle pressure on the skin towards the abdomen and not with the severe force pulling the colostomy bag. Colostomy diarrhea may be complained by the patient in case of ascending or transverse colostomies in case they are not fully explained about the nature of content expected, but stomal diarrhea may be the result of extensive resection with failure of bowel adaptation or if associated with short bowel syndrome. It may also be due to infectious causes like bacterial overgrowth or Clostridium difficile enteritis or secretory tumors like VIPoma, carcinoid, gastrinoma or radiation enteritis or due to medical disorders like hyperthyroidism or adrenal insufficiency in which case the fluid and electrolyte balance of the patient should be restored, with the possible use of anti-diarrhoeal agents and the underlying disorder treated appropriately. In the case of stomal constipation, the stomal obstruction should be ruled out by checking for absent or greatly increased bowel sounds, doing an X-ray abdomen in the anteroposterior view with the patient in the erect posture to rule out proximal obstruction or ileus. Postoperative ileus may be present in the first few days after surgery, and the colostomy should be expected to be functional within 2 to 4 days after surgery, and the period of ileus may be reduced by early patient mobilization and following the ERAS (Enhanced Recovery After Surgery) protocol. Inter bowel adhesions may be a cause of obstruction in the late postoperative period. Enemas or irrigation of the stoma may be taught to patients with reasonably good results, but should be avoided in stoma prolapse, chemotherapy, pelvic or abdominal radiation treatments, diarrhea-producing medication or in case of an irregular functioning stoma and may lead to dependence.

Postoperative ileus may be present in the first few days after surgery, and the colostomy should be expected to be functional within 2 to 4 days after surgery, and the period of ileus may be reduced by early patient mobilization and following the ERAS (Enhanced Recovery After Surgery) protocol. Inter bowel adhesions may be a cause of obstruction in the late postoperative period. Enemas or irrigation of the stoma may be taught to patients with reasonably good results, but should be avoided in stoma prolapse, chemotherapy, pelvic or abdominal radiation treatments, diarrhea-producing medication or in case of an irregular functioning stoma and may lead to dependence. Severe colostomy related complications include stomal gangrene seen commonly in the early postoperative period, stomal retraction, colostomy prolapse, parastomal herniation, mucocutaneous separation along with other surgical complications like SSI’s and wound dehiscence, postoperative atelectasis and pneumonia, urinary tract infections and DVT. Colostomy gangrene may be due to the disease process, if due to ischemia, involving the stoma or due to technical errors like tying the mesentery or making too narrow a defect in the rectus fascia, causing obstruction of the blood supply to the stoma. This should be managed by re-exploration and new stoma creation after resection of the diseased bowel. Stomal retraction is generally detected when the stoma bag is being changed and refers to the condition when the stoma passes below the level of the skin. It may recede inside the peritoneum, which leads to the discharge of fecal content inside the abdomen leading to peritonitis, which is an emergency.

Severe colostomy related complications include stomal gangrene seen commonly in the early postoperative period, stomal retraction, colostomy prolapse, parastomal herniation, mucocutaneous separation along with other surgical complications like SSI’s and wound dehiscence, postoperative atelectasis and pneumonia, urinary tract infections and DVT. Colostomy gangrene may be due to the disease process, if due to ischemia, involving the stoma or due to technical errors like tying the mesentery or making too narrow a defect in the rectus fascia, causing obstruction of the blood supply to the stoma. This should be managed by re-exploration and new stoma creation after resection of the diseased bowel. Stomal retraction is generally detected when the stoma bag is being changed and refers to the condition when the stoma passes below the level of the skin. It may recede inside the peritoneum, which leads to the discharge of fecal content inside the abdomen leading to peritonitis, which is an emergency. Depending on the degree of retraction, it may be managed locally by pull up of the stoma and re-fixation to the surrounding skin or may require laparotomy and re-creation of the stoma with a metallic or plastic stoma rod passed through in the mesentery. This rod maybe even placed during primary surgery to reduce the chances of retraction. If the patient is planned for restoration of continuity soon, the surgery may be preponed and done in the same setting. Colostomy prolapse is commonly seen in transverse colostomies and is generally managed conservatively, however laparotomy with stomal revision may be required, especially in case of large prolapses with irreducibility. It is most commonly seen in the distal limb, especially in conditions where there is distal obstruction.

Depending on the degree of retraction, it may be managed locally by pull up of the stoma and re-fixation to the surrounding skin or may require laparotomy and re-creation of the stoma with a metallic or plastic stoma rod passed through in the mesentery. This rod maybe even placed during primary surgery to reduce the chances of retraction. If the patient is planned for restoration of continuity soon, the surgery may be preponed and done in the same setting. Colostomy prolapse is commonly seen in transverse colostomies and is generally managed conservatively, however laparotomy with stomal revision may be required, especially in case of large prolapses with irreducibility. It is most commonly seen in the distal limb, especially in conditions where there is distal obstruction. A novel method using a stapler device applied directly to the prolapsed stoma at the local stomal site has been found to be effective, reducing the need for laparotomy. A parastomal herniation is due to the creation of a wide defect in the rectus sheath through which the bowel passes and may lie in the subcutaneous plane, or may pass through the stomal opening in the skin if pressure increases. In severe cases, it may lead to bowel incarceration and strangulation. It is most commonly seen with end colostomies. It may be avoided by prophylactic mesh fixation of the stomal site during index surgery, but that might lead to infected mesh if the procedure is an emergency with an infected abdomen. If it does develop, laparoscopic modified Sugarbaker or keyhole procedures are currently in use with the Sandwich repair as an alternative and are found to have lesser rates of recurrence than the open parastomal hernia repair method. In cases where repair is not possible, resiting the stoma to the other side of the abdomen is better than another site on the same side.[8] Mucocutaneous separation can be treated by simply refixing the stoma to the skin edges using less gap between sutures. [9][10][11][5]

Colostomy creation and care is a major abdominal procedure, routinely performed in general surgery departments around the world, but have multiple possible complications as well as a severe psychosocial impact on patients. Thus it is imperative to have adequate preoperative guidance as well as intraoperative decision making and postoperative care so as to minimize morbidity and the psychosocial burden. A team approach is an ideal way to go about this, and the following should be done: The patient should be evaluated by a general or gastro surgeon to assess the necessity of stoma creation. He should be evaluated by a pulmonologist and cardiologist to assess and optimize lung and heart status and also tested for fitness by the anesthesiologist. An enterostomal therapist should then explain the procedure, address any concerns the patient might have, and mark the site for stoma creation. The nurse should teach the patient how to use an incentive spirometer. The stoma should be made by the general or gastro surgeon based on his best clinical judgment. In the postoperative period, the nurses or enterostomal therapist should perform colostomy care with the view to teach the patient how to go about it himself at home and also how to assess for complications. A physical therapist and a dietician should be contacted for early ambulation and parenteral or early enteral nutrition to reduce postoperative ileus. The patient himself performs colostomy care and must look out for complications once he is discharged from the hospital. A psychologist may be required to assess and address any psychosocial complications the patient might have regarding the colostomy or the appliance. An integrated team approach is seen to be vital in colostomy preparation and management and has also been seen to reduce complications related to stoma creation as well as for psychosocial support. [Level 5]

An integrated team approach has been seen to be essential in colostomy care. Colostomy care in most surgical wards around the world is done by the nursing staff and allied health care workers. The nursing staff and enterostomal therapists help in deciding and marking the stoma site in the preoperative period. In the postoperative period, they teach patients how to manage and change their colostomy appliances as well as how to look out for complications. Dieticians help patients in the postoperative period by preparing a diet chart individualized for the patient, based on his weight and the amount of bowel resected and the amount of functioning bowel. They also help to reduce and manage postoperative ileus. Psychologists help manage the psychosocial aspect of colostomy creation and conduct counseling sessions and send patients to colostomy support groups. Physical health therapists help in early patient ambulation in accordance with the ERAS protocol to decrease postoperative ileus and decrease the chances of developing DVT.[12][13]

Monitoring in colostomy care is an integral aspect to assess for complications and to plan for colostomy closure. It is generally done in hospitals by a team of allied health workers and the nursing staff. In the hospital setup, in the early postoperative period, the nursing staff must check for viability and full functioning of the stoma and also look for complications like stoma gangrene. Also, general surgical complications like post-op DVT, atelectasis, and UTI must be looked for. After discharge, the patients must be followed every couple of weeks to look for complications like stomal prolapse, retraction, and parastomal herniation. This is generally done by the nursing staff and, in case of complications, must be communicated to the treating surgeon for appropriate action. The patients’ weight and body mass index (BMI) should be calculated at regular intervals by a dietician and be advised appropriate dietary and fluid management advice as well as vitamin and mineral supplementation to compensate for the reduced bowel length and reduced absorption. The mental status of the patient should also be assessed at regular intervals, before and after stoma creation, by a psychologist.