GI stoma

Supervised by :Dr.Mahmoud
Awaisheh
presented by :
- Israa Tarawneh
- Rama Hreseh
- Huda AL-Majali
 surgical stoma
- A surgical opening (from the body surface) into a hollow viscus

- stoma is an artificial opening made in the colon or small

Intestine to divert feces and flatus out- side the abdomen where
they can be collected in an external appliance. (Colostomy &
ileostomy)
 Types
According to the length of time to be used:
1- Temporary stoma
2- Permanent According to the origin:
1- Colostomy
According to the method of construction: 2- Ileostomy
1- End stoma: single 3- Gastrostomy
4- Jejuostomy
2- loop stoma: two openings connected to the same mucosa (not
skin) 5- Esophagostomy
3- Double barrel
 Indications for stoma:
inflammatory bowel disease
ulcers
polyps
Cancers: - Coloncarcinoma -Rectalcarcinoma
Disorders of bowel function — Hurschprung’s disease
Accidental injury
Congenital deformities of anus and rectum
Operative:
1.distal anastomosis
2.distal repair
3. Hartmann's operation
Normal stoma :
Above the skin level
Red and moist
Normal surrounding skin
it has no nerve endings, so it is not

painful to touch as no nerve endings,

so it is not painful
to touch.
 Choosing a stoma site
The optimum site of stoma will depend on the type of stoma, previous incisions, scars, the
patient’s build, and clothing habits
The optimum stoma site must be accessible, visible, and comfortable to the patient.

A stoma site should have the following criteria:

• It should be at least 5 cm away from the planned incision line to reduce

the risk of prolapse, hernia, and stoma retraction .

• The stoma site should be away from creases, scars, the umbilicus, and
bony prominences .
 Examination of patient presenting with
intestinal stoma

1 – Inspection :
• 2 – palpation :
site : RIF , LIF
• Feel around the stoma site for any tenderness
Number of opening
Color : Red , black • Ask patient to cough and feel for a cough
Output : volume + consistency impulse for any parastomal hernia
Surrounding skin : clean and dry
Spout : present or not
Any evidence of complication : hernia, prolapse ,,, • 3 – Auscultation :
• Auscultate for bowel sound
 Digital examination of stoma

It includes the insertion of a gloved lubricated index

finger into the stoma lumen.
At times, this may be all that is needed to relieve an
obstruction due to adhesions or fibrosis.
The removed gloved finger is then inspected for feces,
blood or mucus.
 Ostomies and preoperative stoma
plannig
PRE-OPERATIVE NURSING CARE
Psychological preparation: Assure the patient that 'Ostomy' can be cared for without it
interfering with daily activities and social life
Nutrition: A low residue diet is given for at least 1-2 days prior to the surgery.

• Care of the Bowel: "Sterilization" of the bowel prior to surgery to reduce bacterial flora
can be achieved through administration of poorly absorbed antibiotics such as
neomycin 1grm 4 hourly for 1-3 days;
• Laxatives and enema may be done
 POST-OPERATIVE NURSING CARE

Skin Care: Access skin for sign of irritation or breakdown; apply skin barrier paste.

• Control of Odor: control odor by a clean odor free, well-fitting appliance; regular change of
bag, cleaning

• Applying an ostomy appliance: The stoma must be measured so that the right size appliance
can be chosen. The pouch attaches over the stoma and is fastened unto the faceplate.

• Medications: Some medications or nutritional supplements may change the color, odor, or
consistency of stool just like before surgery. Patient education and post-medication
observation are therefore necessary.
 (1) Ileostomy

Definition: is an spouted artificial opening (usually in RIF) made in the any part of the mid or distal small
intestine to divert feces and flatus out- side the abdomen (fluid Output: continuous) where they can be
collected in an external appliance.

The best site is usually through the lateral edge of the rectus sheath, above and medial to the bony
prominence

Ileostomies are positioned spouted to the skin (no (no flush, 2-3 cm) because the enzymes present in
small bowel contents are more alkali and, therefore more irritating to the skin.
 Types

A. Loop ileostomy (Temporary):

o often used for non-functioning low rectal anastomosis or an ileal pouch
o A knuckle of ileum is pulled out through a skin trephine in the right iliac fossa.
o in these cases, the stoma will have two openings, although they'll be close together and you may not
be able to see both.
o The advantages of a loop ileostomy over a loop colostomy are the ease with which the bowel can be
brought to the surface and the absence of odour
B. End ileostomy (Can be permanent or temporary, but most likely permanent):
sometimes required after total proctocolectomy or in patients with obstruction or After a subtotal
colectomy without anastomosis when it may later be reversed
The ileum is normally brought through the rectus abdominis muscle.

While ileostomy output can amount to 4 or 5 liters: per day, losses of 1-2 liters are more common.
consistent ileostomy output in excess of 1.5 liters Is usually associated with dehydration and sodium
depletion in the absence of intravenous therapy.
 (2) Colostomy
• Definition: is a planned opening made in the colon to divert feces and
flatus outside the abdomen (solid or semisolid Output: episodic, not
continuous, Bad odor) where they can be collected in an external
appliance.
 1 - According to anatomical location
colostomies are :

1- end sigmoid colostomy : left iliac fossa

2- end descending colostomy : left iliac fossa
3 – transverse colostomy : above and right to umbilicus
4 – caecostomy : right iliac fossa
 2 – according to duration :
Temporary colostomy:
May be required to give a portion of the bowel a chance to rest and heal. When healing has
occurred, the colostomy can be reversed and normal bowel function restored.

Permanent colostomy:
May be required when a disease affects the end part of the colon or rectum .
patients with distal rectal cancers who require anabdomino-perineal resection.
Severe “inflammatory bowel disease” with involvement of the sphincter mechanisms
Weak sphincter muscles and/or fecal incontinence that’s not responding to other treatments.
 1) Loop colostomy

is made by: bringing a mobilized loop of colon to the surface, where it is held in place by a
plastic bridge passed through a mesenteric window created just at the junction with the colon.
Once the abdomen has been closed, the colostomy is opened, and the edges of the colonic
incision are sutured to the adjacent skin margin.
When firm adhesion of the colostomy to the abdominal wall has taken place, the bridge can be
removed.
Most commonly used as temporary colostomy done on transverse colon in emergencies
Following healing of the distal lesion for which the temporary stoma was constructed, the
colostomy can be closed.
- Advantages: Easy reversal

- Disadvantages:

1. Larger abdominal wall defect, and stoma opening

2. More prone to develop parastomal hernias, prolapse and peristomal sepsis.

It is now less commonly employed, as it is difficult to manage and potentially disrupts the marginal
arterial supply to the anastomosis.
(A loop ileostomy is now more commonly used)
 2. End colostomy
This is formed after an abdominoperineal excision of the
rectum or as part of a Hartmann’s procedure
The proximal end of transected colon brought to the skin for
stool drainage.
Single opening (permanent usually)
The site usually in the left iliac fossa.
Smaller and easier to manage.
Lower incidence of parastomal hernia formation
andprolapse.
 Hartmann's operation

The surgical resection of the rectosigmoid colon followed by

creation of an end colostomy with closure of the rectal stump.
Usually an emergent temporary procedure to treat bowel
perforation, infection (e.g., diverticulitis), or obstruction if
primary anastomosis is deemed unsafe.
Then surgical re-anastomosis with restoration on intestinal
continuity (~6 months following initial operation)
Can be permanent when carried out as a palliative measure
for colon cancer
 3) double-barreled colostomy
Has two ends are brought out into the abdomen as 2
separate stoma:
1 - (proximal end) functional stoma: which is still
connected to the gastrointestinal tract and will therefore drain
stool.
2 -(distal end) : non- functioning (mucus fistula);
connected to the rectum

Used in temporary diversion – when resection of section of

colon has occurred but the patient is too ill to undergo a safe
reanastomosis
 Stoma bags and appliances:

stoma output is collected in disposable adhesive bags.

lleostomy appliances tend to be drainable bags, which are left in place for 48 hours,
while colostomy appliances are simply changed two or three times each day.
A wide range of such bags is currently available. Many now incorporate an adhesive
backing, which can be left in place for several days.
 Complications
I. Intraoperative—occurring immediately in the operative room.

II. Early—occur 1–30 days after surgery.

III. Late—occur after more than 1 month of surgery.

 (1) Peristomal dermatitis
- It is the most common stoma complication. It is characterized by skin
irritation around the stoma.
(causes) • The most common symptoms are itching,
1- Irritation. burning sensation, and pain.
2- Contact with the products used in
colostomy.
3- Contact allergy.
4- Mechanical trauma.
5- Bacterial or fungal skin infection.
(management)
- The use of azoles is the best first-line
treatment.
- If antifungal treatment does not clear the
problem, it is likely to be bacterial and an
antibacterial powder is indicated such as
sucralfate powder.
 (2)Necrosis/Ischemia
Necrosis may occur when the blood flow to or from the stoma is impaired or
interrupted, resulting in severe tissue ischemia with impairment of stoma viability or
tissue death.
Initially the mucosa turns pale evolving to a purple, brown, and black color. The
consistency becomes soft or hard and dry with loss of the characteristic brightness of a
normal mucosa.

(causes)
- tension or stripping .
- Sutures too narrowly spaced, or constricting
sutures.
-embolization.
- Abdominal structure anomalies
 (management)
- In cases of superficial or partial mucosal necrosis observation is the best approach.
- In cases of deep mucosal necrosis, a surgical intervention is indicated.

Partial necrosis Extensive necrosis

 (3)Retraction
A retraction of the stoma occurs when the stoma lays flat to the skin or below the skin
surface level.
Can be partial or complete.
can occur early or late.

(causes)
- Exteriorization
of intestinal loop under tension, insufficient stomal length,
poor fixation of the loop to the abdominal wall, or lack of stoma support.
- Secondary to abdominal structure anomalies.
- The premature removal of the loop device to support the intestine outside the
abdominal wall.
- later scar formation
 (consequences)
- Patients with retracted stomas present with effluent undermining the pouching
system, persistent leakage, shortened pouch wear time, and resultant peristomal
irritant dermatitis.

(management)
- Conservative treatment with convex devices
attached to the belt and protective skin pastes.
- Surgical intervention (stoma revision).
 (4) Prolapse
Is the telescoping of the bowel out through the stoma.
Prolapse can be partial or complete, and either the distal or the proximal segment of the loop ostomy
may prolapse.
Can be classified as sliding or fixed.

(causes)

- Weak abdominal wall

- Creation of excessively large opening in the abdominal wall.
- Positioning the stoma out of the rectus abdominal muscle.
-Postoperative increase of the abdominal pressure.
-Bowel edema.
- Inadequate fixation.
 (clinical manifestation)
Makes the stoma longer and more susceptible to abrasion or infection.
Makes the patient’s ability to conceal the stoma beneath clothing difficult.
Makes the stoma more susceptible to bleeding and more prone to trauma.
A prolapsed stoma could also become obstructed.

(management)
- Conservative management.
-Surgical correction of prolapse.
 (5) Parastomal hernia (PSH)
A protrusion of the bowel or loops of intestine through the fascial opening into the subcutaneous tissue
around the stoma.
may be partial or circumferential.
The hernia change in position.
Occurs months to years after surgery because of surgical technical error or following gradual
enlargement of the fascial defect.

(risk factors)
- Intra-abdominal pressure.
-Advanced age.
-Obesity.
-Chronic cough.
- Long-term use of corticosteroids.
 (clinical manifestation)
- Most patients are asymptomatic.
- Symptoms include mild peristomal discomfort, stoma appliance issues with leaks
and skin irritation , obstruction, and strangulation.

(management)
• CT scan with oral contrast confirms the diagnosis.
• Asymptomatic patients can be treated conservatively.
• If signs of obstruction, incarceration, perforation, or recurrent pouching difficulties are present, the
patient should be referred to a surgeon.
• Surgery repair of parastomal hernia can be done by fascial repair, prosthetic mesh, or stoma
relocation.
 (6) stenosis
Is a stricture or retraction of the stomal opening.
The symptoms include abdominal excess of gases, frequent cramps and diarrhea, as
well as thin feces.

(causes)
- Inadequate excision of the skin during construction of a stoma or poor stoma site.
-Stomal ischemia, necrosis, or retraction.
-Recurrent disease.
-Recurrent episodes of skin irritation.
- Weight gain.
- Radiotherapy.

(management)
The best option for the treatment of this
complication is surgery.
 (3) Gastrostomy
Definition: An opening in the stomach made surgically, usually connecting the stomach to the outside of
the abdomen so that a feeding tube or gut decompression tube can be passed into the stomach.
Indications:
Neurological swallowing disorders e.g cerebral palsy, multiple sclerosis etc
Esophageal stricture or atresia
Esophageal cancer
Gastric outlet or small bowel obstruction
Major neck surgeries
Any condition which requires prolonged tube feeding for > 4weeks.
 Types
Open gastrostomy
Percutaneous endoscopic gastrostomy (PEG)
- The principle of a sutureless approximation of the stomach to the anterior abdominal wall has allowed the pull
technique
Reduced morbidity and mortality compared to open.

Complications
• 1) Infection

• 2) Trauma to other structures eg colon

• 3) Hemorrhage

• 4) Leakage

• 5) Blockage

• 6) Aspiration pneumonia

• 7) Displacement of tube
 (4) Jejunostomy
Definition: jejunostomy tube (J-tube) is a soft, plastic tube placed through the skin of the abdomen
into the midsection of the small intestine. The tube delivers food and medicine until the person is
healthy enough to eat by mouth.
Indication:
Gastric outlet obstruction
Gastric enteral feeding is contraindicated
Central nervous system disorders
Chronically ill
 Complications
Minor bleeding from the site
Local infection
Granulation tissue formation
Tube dislocation
Obstruction or migration of the tube
Intra-abdominal abscess
Enterocutaneous fistulas
leakage from the catheter
Perforation of the small intestine
Electrolyte disorders
Vitamin, mineral and trace element deficiencies
 (5) Esophagostomy
Definition: This procedure can be performed as a temporizing procedure for an esophageal
perforation when a primary repair cannot be performed.
Cannot use in excessive vomiting (contraindication)
Indications:
Esophageal perforation in patients too ill to tolerate thoracotomy
detection of esophageal perforation or suture line breakdown at a time too late to permit
primary repair.
benign or malignant obstruction of the esophagus associated with persistent pneumonitis.
Complications:
• Vomiting
• Scratching at the tube and bandage
• Patient removal of the tube
• Inflammation
• Infection at the wound site and
• Mechanical issues