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Stomas - Coggle Diagram
Stomas
Ileostomy
Def
Connection between the lumen of the distal small bowel and skin
Location
Usually right iliac fossa
Content
Small bowel content
Spout
SPouted due to effluent
Effluent
Continous
Liquid or past like consistentcy
Green in colour
Highly alkaline
High in active enzymes
Corrosive to skin
End Ileostomy
Features
Single spouted
Usually right iliac fossa
Indications
Panproctocolecomy (permenant)
Emergency colectomy (temp)
Emergency right hemicolectomy (temp)
Making
Loop Ileostomy
DEfuntioning Loop Ileostomy (DLI)
FEatures
Making
Colostomy
Definition
Connection between lumen of colon and skin
Location
Usually left iliac fossa
SPout
Unspouted - flush skin
Indication
When necessary to remove distal colon and not possible or advisable to preform anastomosis or to bypass distal obstruction
Effluent
Intermittent
Solic of semi-formed stool
Less corrosive to skin
Lower output than ileatomy
End Colostomy
...
Loop Colostomy
...
GI Stomas
Gastrostomy
Feeding
VEnting (PEG / RIG)
Duodenostomy
Rare
Jejunostomy
Typically for feeding / Large amount of resected bowel
Ileostomy
Caecostomy
PAeds
Emergency decompression
Colostomy
Locating Stoma
Poor stoma placement makes mx of stoma difficult and worsens QoL
BEst over rectus sheath
On flat surface
Away from irregular surfaces, incisions, boney prominences
PReferred bewlo belt line - facilitates hiding of stoma bag
Site marked preop by stoma urse and checked with pt standing and siting
Non-GI Stoma's
Urostomy
Tracheostomy
Nephrostomy
Thoracostomy
Complications
Very Early (days)
Usually related to technical factors
Stoma necrosis
Too much tension on mesentery facial opening too tight
Excess use of vasopressors causing splanchic vasoconstriction
Stoma retraction
Too much tension
Obstruction
Fascial opeing too tight
Twist in mesentery
Stomal bleeding
EArly (<3 months)
Due to poor site selection or Pt factors - Smoking, obesity, malnutrition, steroid use
Stoma retraction
Mucocutaneous seperation
Stoma necrosis
LAte (>3 months)
Typically seen in permanent stomas as temporary should be reversed around this time
Stoma stenosis
Stoma prolapse
Stoma Retracntion
Para stomal hernia
Can occur earlier but this implies technical failure
Any time
3 main types
Peristomal skin problems
Psychological
High output
Normal output - <1500ml/day
High output more common in ileostomies or more proximal sqtomas (jejunostomies in particular) due to lack of colon to reabsorb water
Infx causes
Infective enteritis
Colitis
Can lead to dehydration & electrolyte imbalance
Definitions
Stoma
Mouth
Ostomy
Artificial Connection between a hollow viscus and the skin
Indications
Decompression (Obstruction)
Congenital anorectal anomalis
Relief of distal obstruction
Diversion (DEfunctioning)
Protect a distal anastomosis (ileorectal anastomosis)
Contamination (Perforation)
Exteiorization (trauma)
Naming Stomas
Number of Lumens
1 lumen → end stoma
Often permenant
After major resection
APR
Ileostomy after PPC
Hartman
2 lumen → loop
Easy to make
Easy to close
Usually temporary
Use mobile segment (transverse colon, sigmoid, ilium)
Involved bowel
Ileum
End / Loop Ileostomy
Colon
Loop / End Colostomy
Temporary Vs Permanent Colostomies
Temporary
Electively to protect low-lying anastomosis (but DLI more common)
Electively to allow perianal sepsis to be controlled
Emergently to prevent perforation
Permanenet
Post APR
Perianal sepsis not reponding to medical therapy
Faecal incontinence
Post anterior resection in frail pt who could not tolerate leak
Decompression
PT with obstructing lesions may need colostomy to decompress the bowel to prevent perf
Types
Transaverse loop colostomy
Caecostomy (can be done IR)
Sigmoid loop colostomy
DEfunction
Temporary
Inx
Low colorectal anastomosis (<5 - 7cm from anal verge)
Previous pelvic irradiation
Impaired wound healing - steroids, immunosuppressants
AFter pouch formation
Pt planned for adjuvant chemotherapy
Indicated in pt with anastomosis of high risk to breakdowon
MX Complications
High Output Stomas
Investigation
Hx and Exam
Indication
Clinical signs of dehydration
Biochem
Renal profile
Mg , Phosphate
FBC
Enteric profile
Other
Stoma output culture
CT
Mx
Conservative / Fluids
ORal fluid restriction
Ovoid hypotonic oral fluids - prefer hypertonic solutions (St-Marks pr Double-Dioralyte)
Replace electrolytes
IVF supplementation
Involve dieticians early
Pharm
May need
Loperamide 2-16mg BD-QDS
PPI - reduce gastric secretion
Codeine phosphate
Octreotide if refractory
ST Mark's or Double Dioralyte