Ostomy Complications

AJ De Witte

Definition

  • Nomenclature: segment of the bowel used (sigmoid, colon, ileum), surgical construction (loop, end, reservoir), duration (temporary vs permanent)
  • Highest complication rates: loop ileostomies
  • Lowest complication rates: end ileostomies/colostomies

Presentation/Management

  • Very Early Complications (days)
    • Operative technical issues (ie, LBO) - return to OR
  • Early Complications (<3 months)
    • Suboptimal stoma site selection + high risk patient factors (ie, nutrition, age, tobacco use).
      • Stomal Necrosis
      • Stomal Bleeding
      • Stomal Retraction
      • Mucocutaneous Separation
    • Management: EGS/colorectal and ostomy team consult
  • Late Complications (>3 months)
    • Gas
      • Diet (starch and soluble fiber) vs gas ingestion (drinking straws, chewing gum, smoking)
      • Management: dietary modifications, OTC meds, flatus filters if unresponsive
    • Dehydration/high ostomy output (>1.5 L/day):
      • Common in loop ileostomy
      • Management: psyllium husk (1st line), antimotility agents +/- IVF (2nd line).
      • Additional management: octreotide, cholestyramine, tincture of opium.
    • Parastomal Hernia
      • No action needed unless incarcerated/strangulated/bowel obstruction
    • Stomal Prolapse
      • Telescoping of the intestine out from the stoma with risk of intestinal edema, incarceration
        • Uncomplicated prolapse: cool compresses +/- application of osmotic agent, followed by manual reduction + abdominal binder.
        • Complicated prolapse: ischemia +/- bleeding, urgent EGS consult
    • Stomal Stenosis
      • Mild stenosis: diet (avoidance of insoluble fiber) +/- routine dilation.
      • Severe Stenosis: cramping, explosive output. Surgical correction.
    • Mechanical Trauma
      • Routine peristomal hair trimming and plasticizing skin sealants with pouch removal
    • Dermatitis
      • Severely denuded skin, most common with ileostomy.
      • Management: barrier powder + removal of allergen, nystatin/miconazole powder (if fungal), topical steroids (refractory cases)
    • Granulomas
      • Red, moist, elevated lesions (+/- bleeding) at the mucocutaneous border usually from retained extraneous material.
      • Management: removal of extraneous material + Silver nitrate.
    • Peristomal Pyoderma Gangrenosum (PPG)
      • Neutrophilic dermatosis, pathergy (avoid biopsy), seen in IBD
      • Management: mild (topical steroids vs tacrolimus, wound care); severe (systemic steroids +/- anti TNF, surgery)
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