Overview of Colostomy Care
A stoma is a small opening made during surgery on the front part of your belly. This opening is made to allow waste to leave your body. This is usually done to give the rest of the bowel a chance to rest or heal.
A colostomy is a specific type of stoma, where a part of your colon (large intestine) is attached to this opening. This is usually done to treat certain diseases, to help with a blocked bowel, or to prevent the rest of your bowel from getting dirty from waste.
This new opening made to help waste leave your body can either be temporary or permanent, depending on why you needed it. Usually, you can’t control when waste or gas will pass through this opening.
That’s why care for this opening, commonly referred to as colostomy care, is crucial after the creation of a colostomy. Colostomy care involves a whole list of things, including managing the new opening to your bowel, keeping the skin around the opening healthy, using apps or devices designed for handling a colostomy, and even mental health support throughout this process.
The aim of colostomy care is to protect and take care of the skin around the opening, help patients accept and adapt to their new body condition, and prevent any potential issues related to the colostomy.
Anatomy and Physiology of Colostomy Care
The large intestine begins at a part called the cecum and continues upward to the so-called ascending colon (with a bend known as the hepatic flexure), travels across to the transverse colon (with a bend called the splenic flexure), goes down to the descending colon, and finishes with the sigmoid colon. As our food waste travels through the colon, it becomes more solid due to the absorption of water and electrolytes in the large intestine.
In cases where a colostomy — a surgery that brings one end of the colon out through the stomach wall — is necessary, the most common types are the sigmoid colostomy and the transverse colostomy. Rarely performed are the ascending and descending colostomies. The specific type of colostomy depends on several factors, including the problem being addressed, the length of the mesocolon (the tissue that attaches the colon to the back wall of the abdomen), and the amount of healthy and diseased bowel.
The stool that passes through different types of colostomies varies quite a bit. It can be anything from a soft and loose, unpleasant, oatmeal-like stool in the ascending and transverse colostomies to a firmer, paste-like stool from the transverse and descending colostomies. Stool from a sigmoid colostomy typically resembles a normal bowel movement. As the stool becomes more solid along the colon, it becomes easier to manage.
To make a colostomy, surgeons create an opening on the surface of the stomach, typically over the rectus abdominis muscle (a long muscle on either side of the abdomen), below the belly button. In overweight patients, the site may be above the belly button because that part of the stomach has less fat. During the procedure, a circular cut is made over the site where the stoma (the opening that will be created on the surface of the stomach) goes. The spot needs a flat surface of about 2 to 3 inches and should be away from the beltline, any scars, and bony bumps to make sure the stoma appliance seals properly.
Next, the surgeon pushes the rectus muscle to the side. Afterward, a segment of bowel to be used for the stoma is pulled through the cut and brought out to the skin. Performing a diagnostic laparoscopy, a type of small incision surgery using a camera, can help identify the bowel. This procedure ensures the bowel’s mobility and the ease with which it reaches the stomach wall. The stoma can also be created without a laparoscopic approach if necessary. Prior to surgery, doctors will have used imaging techniques to determine the most mobile segment of the bowel and mark the colostomy site accordingly. Depending on the type of colostomy, locations can vary. A transverse colostomy generally goes in the left upper quadrant of the stomach, while a sigmoid colostomy goes in the left iliac fossa (an area of the lower left region of the abdomen).
Once the bowel is brought outside, a stoma rod can be inserted through the mesocolon to keep it from retracting back into the abdominal cavity. The colon is then cut most of the way around, and the bowel edges are sewn to the skin with absorbable suture material, with the stoma elevated slightly above the skin. Unlike an ileostomy (an operation similar to a colostomy but involves the small intestine), colostomies don’t typically require the edges to be rolled outward because the stool has less enzyme activity.
Why do People Need Colostomy Care
A colostomy, which is a surgical procedure that brings one end of the large intestine to the surface of the skin to create an opening or “stoma,” is performed for various reasons depending on the type of colostomy.
A “double-barrel” colostomy might be done following the removal of a portion of the bowel due to different medical conditions. These include colorectal cancer (cancer of the colon or rectum), a section of dead bowel tissue, inflammatory bowel disease (which causes inflammation throughout the digestive tract), or injuries to the bowel. It may also be done for a condition termed “gangrenous sigmoid volvulus” where a loop of the bowel twists on itself, causing it to die.
A “loop” colostomy might be performed for several reasons. These include penetrating injuries to the abdomen, colorectal cancer, unforeseen injury to the bowel during surgery, an injury to the region around the anus, and diverticular disease causing blockage (where pouches along the wall of the colon get inflamed or infected). It might also be done to protect a surgical connection in the bowel, for problems with controlling bowel movements, or for a severe infection called Fournier’s gangrene, affecting the area around the anus and abnormal connections between the anus and the skin. In newborns, it can serve as an emergency procedure for certain birth defects of the anus or rectum such as an “anorectal malformation” or Hirschsprung disease, a condition that affects the nerve cells in the large intestine, before a corrective surgery can be done.
An “end” colostomy might be needed for certain conditions like a gangrenous sigmoid volvulus, colorectal cancer (usually after a specific surgical procedure called abdominoperineal resection), a complication where the ileum (last part of the small intestine) gets twisted around the sigmoid colon (part of the large intestine), penetrating injuries to the abdomen, ulcerative colitis (a type of inflammatory bowel disease), intussusception (a condition where one part of the bowel slides into the next, like pieces of a telescope), a leak from a surgical connection, anorectal cancer, and injuries to the region around the anus. This type of colostomy involves closing off the lower part of the bowel and attaching it to the abdominal wall. If the colostomy needs to be closed up in the future, it may require exploration of the midline of the abdomen.
When a Person Should Avoid Colostomy Care
There are no specific reasons why a colostomy, which is a procedure to create an opening for the colon, or large intestine, shouldn’t be performed. This operation is often necessary when two parts of the intestine can’t be connected due to a sudden and critical need for the surgery. It might also be needed if the patient is not getting enough nutrients and their blood levels of albumin (a protein that helps maintain fluid balance and transport other nutrients) and other proteins are too low. A colostomy could also be necessary if there isn’t enough bowel, or if the connective tissue attached to the bowel (mesentery) is too short after part of the bowel has been removed, or if there could be too much tension at the site where the two parts of the intestine are stitched together (anastomosis).
Caring for the opening created by the colostomy (the stoma) is necessary in all cases. However, some methods, like using water to clean out the bowel (irrigation) or putting fluid into the rectum to encourage a bowel movement (enema), should not be used if the stoma sticks out more than usual (prolapse) or if the patient is receiving treatments that could damage cells, like chemotherapy or radiation to the stomach or pelvis. Care should also be avoided if the patient is taking medication that can cause diarrhea, or if the stoma is not working normally, as this could make the patient dependent on these methods.
Equipment used for Colostomy Care
Taking care of a colostomy, which is a procedure that brings one end of the large intestine out through the abdominal wall, often falls to a nurse or a specialized therapist. However, it’s important for healthcare providers to monitor the skin opening where waste exits (known as a stoma) as there might be times when they have to step in.
There are several different types of colostomy bags available, with the choice depending on the kind of stoma. One option is a 2-piece system, consisting of a base plate attached to the skin, and a removable bag to collect waste. Although it’s durable and lasts a long time, it can be tricky to use and may not always adhere well or fit properly.
Another option is a one-piece system, a single unit where the skin barrier and the bag are combined. This is easier to use but must be replaced every 1 to 3 days. There is also a type of bag that is sealed after use; this is generally for patients who regularly pass waste and needs to be thrown away after a single use.
There’s another version which is open-ended and has a drainable bag, which can be emptied without being detached from the skin. In general, depending on the consistency of the waste, for a colostomy, a closed bag is usually needed unless the waste is very liquid, in which case a drainable bag is more suitable. For an end colostomy, like after certain surgical procedures on the lower part of the colon, there is also the possibility of using a plug to close the stoma.
Colostomy bags come in different sizes which can be used by different people or the same person at different times. For example, at night during sleep, a larger bag could be more suitable, while a smaller bag could be used during physical activity or intimate moments. There are also child-sized bags for pediatric use.
Beyond bags, there’s also the option of stoma caps, which are like lids that cover the stoma. They can be used by certain individuals such as by those with continent ileostomies or those who need to control waste release, and can be worn for short periods of time during the day.
Who is needed to perform Colostomy Care?
When someone is considering getting a stoma – which is a surgically created opening in the body – preparations start well before the actual surgery. This begins when the patient is told they might need a stoma. Some people might get upset or anxious about how they will look or what people will think. So, at this time, they might talk to mental health experts or counselors to help them with their concerns. There’s also a special nurse, called an entero-stomal therapist, who talks with the surgeon about where the stoma could be placed on their body and also marks the spot before the surgery.
After the surgery, nurses might need to use special treatments with substances like glycerine to reduce swelling in the stoma. It’s generally between the second and fourth day after surgery when the stoma starts working, and a bag for collecting waste is attached. This bag is known as a colostomy bag. In the early days, a nurse or the special therapist will help to attach the bag. They’ll also teach the patient or their guardians, if they are children, how to do this at home. They inform them about the different types of bags, how these work, what the waste will look like, as well as possible issues with both the stoma and the bag.
The most important part of caring for a stoma is the patient themselves. Once they go home from the hospital, they have to take care of their stoma and regularly change their colostomy bag. They also need to schedule regular check-ups with their doctor to see if the stoma is healthy or gets any complications. As a general rule, the stoma bag should be emptied when it’s about a third full. This helps prevent it from coming off the skin and from any leakages.
Preparing for Colostomy Care
Having a stoma marked before surgery by a specialist helps to make sure it’s positioned in a spot that’s comfortable for the patient. It is usually kept away from the waist area and any skin folds, to avoid any issues with the colostomy bag, such as it falling off or leaking.
Before or during surgery, a nasogastric tube may be used to relieve pressure in the patient’s bowels. Additionally, a Foley catheter (a thin, sterile tube) is used to empty the bladder to avoid any internal damage during surgery. This also helps to check urine levels, which is very important during emergency procedures.
The process of cleaning out the bowels before surgery can sometimes be recommended, but it varies according to the specifics of each case and the surgeon’s judgment.
Antibiotics are administered just before surgery begins. This helps ward off any possible infections.
When it comes to caring for the colostomy, a nurse or attendant will be provided with all the necessary supplies, including the colostomy bag, medical paste, and scissors. A protective sheet is placed under the patient, and the caregiver will use gloves for hygiene.
How is Colostomy Care performed
A colostomy pouch needs to be replaced every 5-7 days, however this largely depends on the type of pouch used. Usually, people take care of this themselves or with the assistance from someone else, like a family member or caregiver, or a parent if it’s for a child. If you see any signs of skin damage or irritation, or if the colostomy (the opening where the pouch is attached) looks different, it’s important to have a healthcare professional see it.
Before you change the pouch, make sure you have all the items you need. You should also wash your hands and put on gloves. Firstly, empty the used pouch and then carefully peel off the adhesive part, commonly known as flange, that sticks to the skin. You might need to pull gently on the pouch or flange while holding your skin to do this. If required, a product to dissolve the glue can be used. The area around the colostomy, referred to as the parastomal area, should be gently cleaned with water (no soap) and patted dry. When cleaning, dabbing is better than scrubbing.
The colostomy should look moist, above skin level, and pink or red, and the skin around it should look normal. If anything seems different, you should tell your doctor. The colostomy should be measured to ensure the size is not more than 1/16-1/8 inch so that an appropriate pouch can be selected.
The skin around the colostomy needs to be perfectly dry to ensure the new pouch will stick properly. Adhesive pastes or powders may also be applied on the skin around the colostomy to help fix the pouch. Once you’re done, remove the protective paper from the pouch’s adhesive part (keeping the tape around it in place), align it around the colostomy and hold it against your skin for 1 to 2 minutes to make sure it sticks well. If your pouch is of the “two-piece” type, you would now need to attach the bag part to the flange. A belt can be used to keep the pouch securely in place. After you’re done, don’t forget to safely dispose of the used pouch, wash your hands and note down the procedure.
Also, it’s important to assess mental health as dealing with a colostomy can be emotionally challenging due to changes in body image perception, sexual dissatisfaction, and depression, which are quite common. You may need support or counselling to help you cope and deal with having a colostomy, so don’t hesitate to seek help if this is the case for you.
Possible Complications of Colostomy Care
People with stomas, which are artificial openings made in the body following surgeries like colostomies, need regular check-ups from doctors and nurses to spot potential problems. These could be obvious problems that bother the patient a lot, or less visible ones that need careful inspection to find.
Minor issues might include bad smells, needing to empty the stoma bag too often, or leaks from the bag. Certain foods can make the smell worse, so avoiding things like fish, eggs, or onions could help. Using deodorants designed for stomas or special odor-resistant bags can also work. Pre-surgery planning and comforting chats with patients after the operation can help stop frequent leaks.
Bigger problems can include pain, skin rashes around the stoma (known as excoriation), diarrhea, constipation, and needing to wash out the stoma (irrigation) or use suppositories (enemas). Applying creams and making sure any stoma appliances fit correctly can help with pain and skin irritation. Changing stoma bags regularly can also help, especially if the bag is removed slowly and carefully.
Diarrhea can happen for different reasons. Sometimes, it’s because patients don’t know what to expect with the content of their stoma. Other times, it could be due to infection, certain types of tumours, radiation treatment, or disorders like hyperthyroidism. If patients experience diarrhea, fluids and electrolytes should be restored and the underlying disorder should be treated as needed. In case of constipation, it is important to ensure there is no blockage in the stoma. Early patient movement and following the ERAS (Enhanced Recovery After Surgery) protocol can reduce the time it takes for the stoma to start working after surgery. There may be the need to irrigate the stoma as well but this should not be done if there are certain complications.
Very serious problems could include the stoma turning black, retracting into the body, falling out (prolapsing), hernia (bulging) around the stoma, separation of the stoma and skin, surgical site infection, wound opening, lung-related issues, urinary infections, and deep vein thrombosis (blood clots). It’s important to react properly in such situations. For example, a retracting stoma needs to be managed locally by pulling the stoma back out and attaching it to the skin securely or it may require a more intensive procedure to fix. Similarly, a prolapsed stoma is normally handled delicately, but severe cases may need surgical correction. A hernia near the stoma might require different surgical procedures or moving the stoma to a new location.
If the area where the stoma meets the skin splits apart, the stoma can be reattached to the skin using stitches closer together.
What Else Should I Know About Colostomy Care?
A colostomy is a common surgical procedure where the doctor creates an opening (stoma) in the patient’s abdomen. This opening is connected to the colon, which is part of the large intestine. The main reasons for this surgery are to let waste (stool) be removed from the body through the stoma or to protect a newly constructed join in the intestine. The most frequently performed colostomy is an end colostomy that follows a surgery known as the Hartmann procedure.
Looking after a colostomy requires teamwork of a group of health professionals. Their tasks include deciding the perfect spot for the stoma before the surgery, offering mental support for patients, doing the colostomy, managing the stoma right after surgery in case of things like intestinal blockage and swelling around the stoma, and helping patients to apply and remove colostomy bags that collect the waste.
It’s also vital to teach both patients and their caregivers how to properly apply and dispose of the colostomy bag. They should also learn to identify any issues related to the stoma. This educational work is often performed by a health professional called an enterostomal therapist, particularly during the recovery period after the surgery.
After the colostomy, it’s important for the patient to see the doctor regularly. During these visits, the doctor will check the condition of the stoma and see if there are any complications. The doctor will also observe the progress of the medical condition that required the colostomy. Furthermore, the doctor will consider closing the colostomy if it was meant to be temporary.
