Penelope Taylor, RN, SCM, Dip Aromatherapy, Cert Counselling.
Clinical Nurse Specialist, Stoma Care, Birmingham Specialist Community Health NHS Trust, Selly Oak, Birmingham
This paper explores some of the complications that may occur following formation of a stoma. All of the complications described can have a deep impact on a person with an ostomy, affecting physical, psychological and social well-being. The most common stomal complications are listed in Box 1.
Poorly sited stoma
A poorly sited stoma may mean the appliance cannot be fitted securely and may leak, causing sore skin. Stomas should be sited pre-operatively wherever possible, avoiding scars, skin folds and bony prominences. The stoma must not be sited on the waistline and should be in a position that is visible and accessible to the patient.
Experiencing a leakage from a stoma pouch can have a devastating and long-lasting effect on a patient. Soiled clothes and faecal/urinary odour can be highly embarrassing if this leakage occurs in public. Such an experience may prevent patients from venturing out in public again and, if they do, may lead them to always carry a change of pouch, and often a change of clothes as well (Myers, 1996).
The best management for a poorly sited stoma is surgical intervention to re-site the stoma. However, there are a group of patients for whom this is not the treatment of choice as surgery would carry too high a morbidity or mortality rate. It is therefore essential for the nursing team to support these patients both physically and psychologically and all that is possible must be done to prevent leakage. There is a vast range of appliances and accessory products available to help manage this problem.
This is usually an early postoperative complication and normally requires surgical intervention. If the necrosis is not the full thickness of the stoma, however, a patient may be discharged into the community. The necrotic tissue will slough away. It has an offensive smell and therefore requires a good pouching system to contain the odour. The patient will also need a lot of support as this can take a great toll on their psychological well-being.
Reassurance that the pouches are odour-proof should be given and the use of ostomy deodorant sprays may be of benefit. Figure 1 shows a stoma that has become necrotic.
Stenosis is the narrowing of the lumen of the stomal outlet. This can occur after necrotic tissue has healed. Unlike normal tissue, scar tissue has no elasticity and so forms a constricting band around the stomal outlet. Surgical intervention is the usual method of treatment for this condition.
There are times, however, when surgery is contraindicated and the patient may be required to dilate the orifice each day. The support these patients will need, physically and psychologically, can come from the community nursing team, stoma-care nurse and national and local self-help groups.
A retracted stoma is one where the stoma has sunk into a skin fold or dip in the abdomen. It may be caused by a poorly healing mucocutaneous junction that causes the stoma to slide back, or by a change in body shape through weight gain.
If the retraction is due to weight gain it may be helpful to advise the patient on losing weight. If it has sunk because of skin folds it may be necessary to use a convex pouch.
A multidisciplinary approach to managing the patient’s holistic well-being in this situation is required. For example, the nurse should ask:
- Does the stoma need refashioning? The patient should be referred to the surgeon
- Is a convex pouch needed? The patient should be referred to the stoma-care nurse
- Does the patient need to lose weight? Referral to a dietitian may be helpful.
A stoma has prolapsed when a length of bowel protrudes out onto the abdominal wall (Figure 2). Prolapses may occur with any type of stoma but are more common in the transverse loop colostomy (Stoddart, 1996). Treatment for this condition is surgery where possible, but a significant number of patients can receive no treatment. A prolapsed stoma, if large, can make it difficult to correctly place a pouch. There are now some large pouches available on FP10, which can ease the management problem, as they are of sufficient capacity to contain the prolapse and the effluent.
A parastomal hernia may occur with any type of stoma. Herniation is an abnormal amount of intestine in the subcutaneous or interstitial tissues (Figure 3). When presented with such a hernia there are three options:
- Do nothing (if surgery is contraindicated or the patient does not want any intervention as the hernia is not causing problems)
- Surgery. Surgery for this type of hernia is not always successful and may involve re-siting of the stoma. This constitutes a major procedure, which the patient may not be willing to undertake
- Fit an abdominal support garment. These are available on prescription. Dispensing appliance companies such as Frittleworth Medical will help in the measurement and supply of these garments.
Trauma to the stoma
This is not frequently seen. Causes for trauma may include:
- An ill-fitting appliance - the stoma size needs to be checked and corrected as necessary. Figure 4 shows ulceration of a stoma caused by an ill-fitting appliance
- Self-harm - if self-harm is suspected careful assessment should be undertaken and an appropriate referral should be made - possibly to a member of the mental health team
- Major bodily trauma, for example in a road traffic accident
- Contact during sports activities. Protective stoma shields are available if the patient is involved in contact sports such as kickboxing or rugby. ConvaTec produces a shield that is available through either a company representative or their helpline (0800-282254).
The mucous membrane lining of either colon or small bowel, which forms the stoma, has a good blood supply and therefore bleeds easily when traumatised. Trauma may be due to a patient being over-zealous when cleaning the stoma. However, it is important to check whether any blood is coming from the surface of the stoma or from the orifice. Figure 5 shows a case of recurrence of a cancer on the stoma.
If a patient complains of bleeding the nurse should:
- Check the patient’s pouch-changing technique
- Observe the stoma for any changes, for example granulomas or polyps. If present the patient should be referred to either the stoma-care nurse or a doctor
- If bleeding is from an internal source the patient should be referred to the doctor.
‘Pancaking’ is a term used to describe a situation where faecal material remains at the top of the pouch and around the stoma opening, and does not fall to the bottom of the pouch. This may cause leakage. The problem may be resolved by use of a filter cover, and by placing a small amount of tissue paper in the pouch before application. This keeps the pouch’s inside walls apart, allowing faecal matter to fall to the bottom.
The fear of producing an unpleasant smell following stoma formation is uppermost in most patients’ mind. Modern pouches are made of an odour-proof plastic. If there is an odour the likely causes are leakage from the pouch, an ill-fitting appliance or lack of care when cleaning the opening of a drainable pouch.
When a patient complains of odour it is necessary to observe his or her pouch-changing technique and to check for leakage. If there are no obvious problems an ostomy deodorant spray may be useful to overcome the psychological fear of odour.
A fistula may form alongside a stoma. This is usually in a patient with a diagnosis of Crohn’s disease (Hill, 1991) and frequently needs surgical intervention. Should this occur the patient needs referral to the surgical team. While awaiting surgery a good pouching system and optimum skin care is required. These patients often need psychological support as a fistula can mean a relapse of Crohn’s disease, resulting in depression.
Altered bowel habit
People with an altered bowel habit should have a thorough holistic assessment to find a reason for this change. Winney’s (1998) article on constipation looks at contributing factors to an alteration in bowel function. Following assessment for a change in bowel function the nurse should plan care based on his or her findings. The nurse may be able to advise on a healthy diet or refer to another professional, such as an occupational therapist for advice on toileting aids or referral to a doctor if some internal pathology is suspected.
Urinary tract infection
People with an ileal conduit/urostomy have an open and shortened urinary tract system and are therefore more prone to infections. If an infection is suspected a urine specimen should be sent for analysis. The urine should be collected directly from the stoma and not from the pouch. Guidelines for this can be found in the Royal Marsden Hospital Manual of Clinical Nursing Procedures (Mallet and Bailey, 1999).
It is important to prevent infections occurring. Therefore the patient’s pouch-changing and handwashing techniques should be checked. Drinking two glasses of cranberry juice a day is useful in prevention (Busuttil Leaver, 1996).
It is thought that as many as one-third of people with a colostomy and two-thirds of people with ileostomies and urostomies experience skin problems at some point (Lyon and Smith, 2001). This is not surprising when you consider what happens when a pouch is placed on the skin. It may occlude, macerate and irritate the skin and the action of removing the pouch will remove a layer of skin cells. In addition, the patient may have a pre-existing skin condition such as psoriasis that is exacerbated. Advice on the treatment of skin problems should be sought, probably in the first instance from the stoma-care nurse specialist.
This brief paper has looked at complications that may occur in patients with a stoma. It is not intended as a definitive guide to all complications. Stomal problems should be assessed holistically and use made of the multidisciplinary team. The nurse must remember that these physical problems can have an enormous effect on the psychological rehabilitation of this patient group.
There is no one simple answer to any of these stoma problems. However, thorough assessment and full involvement of the multidisciplinary team, nurses can solve problems or reduce their impact and improve patients’ physical, psychological and social well-being.
Taylor, P. (1999) (ed.).Community Stoma Care: A clinical resource for practitioners. London: Emap Publications.
Busuttil Leaver, R. (1996) Cranberry juice. Professional Nurse 11: 8, 525-526.
Hill, G.L. (1991) Ileostomy function. In: Allen, R.N., Keithley, M.R.B., Alexander-Williams, J., Hawkins, C. (eds). Inflammatory Bowel Disease. Edinburgh: Churchill Livingstone.
Lyon, C., Smith, A. (eds). (2001) Abdominal Stomas and their Skin Disorders: An atlas of diagnosis and management. London: Martin Dunitz.
Mallet, J., Bailey, C. (eds). (1999) The Royal Marsden NHS Trust Manual of Clinical Nursing Procedures (4th edn). Oxford: Blackwell Science.
Myers, C. (ed.). (1996) Stoma Care Nursing: A patient-centred approach. London: Arnold.
Stoddart, M. (1996) Research into the incidence and management of prolapsed loop colostomy. In: Proceedings of the 11th Biennial Congress of the World Council of Enterostomal Therapists, Israel. Ontario, Canada: World Council of Enterostomal Therapists.
Winney, J. (1998) Constipation. Nursing Standard 13: 11, 49-56.