Ileostomy – types, physiology, complications and follow-up.

IleostomyPermanent ileostomy is sometimes performed after proctocolectomy for ulcerative colitis; Crohn’s disease, familial polyposis, and other conditions may also require ileostomy. A temporary ileostomy often is used to divert the fecal stream for 3 months when ileoanal or coloanal anastomosis is performed. An ileostomy discharges small quantities of liquid material continuously; it does not require irrigation; and an appliance must be worn at all times.

The optimal position of the ileostomy is in the right lower quadrant. An appliance is placed immediately; it consists of a plastic bag attached to a square sheet of protective material containing a central opening for the stoma. A reusable appliance can be fitted after a few weeks, but modern disposable appliances are so satisfactory that most patients never do change to the other type. Appliances lie flat against the abdomen, adhere firmly to the skin, are inconspicuous and odor-proof, and in most cases need to be changed only every 3–5 days. They are drained at intervals during the day through an opening in the bottom of the pouch.

A continent ileostomy (reservoir ileostomy; Kock pouch) is designed to avoid the continual discharge of ileal effluent that necessitates construction of a protruding stoma and the wearing of an appliance at all times. A reservoir is constructed out of the distal ileum, and the outlet from the reservoir is arranged as a valve so that fluid cannot escape onto the abdominal wall. The reservoir is emptied several times a day by inserting a catheter into the stoma. Continent ileostomy is successful in 80% of patients. Problems with the valve, fistulas, and “pouchitis” (mucosal inflammation) are causes of failure.

Physiologic changes after ileostomy are due to the loss of the water- and salt-absorbing capacity of the colon. If the small bowel is free of disease and extensive resection has not been done, an ileostomy puts out 1–2 L of fluid per day initially. The volume of effluent diminishes to between 500 and 800 mL/d after a month. This loss of fluid is obligatory and is not reduced by manipulations of diet. Obligatory sodium losses are about 50 meq/d greater than in patients with an intact colon, and potassium losses are also increased. Healthy ileostomates (patients with ileostomies) have low total exchangeable sodium and potassium but normal serum electrolyte concentrations. The depletion, therefore, is primarily intracellular. The ileostomy patient is susceptible to acute or subacute salt and water depletion manifested by fatigue, anorexia, irritability, headache, drowsiness, muscle cramps, and thirst. Gastroenteritis or diarrhea from any cause and exposure to hot weather or vigorous exercise are situations that require caution; salt and water intake must be increased in these circumstances. Ileostomy patients must never be in a position where salt and water are unavailable, eg, on long hikes in the desert. Low-salt diets and diuretics may also induce salt depletion or dehydration. Patients should be counseled to salt food liberally, but salt tablets will not be required in usual circumstances. Patients with unusually high ileostomy outputs may need supplemental potassium in the form of bananas. Water intake in response to thirst may not be adequate to maintain hydration, and patients should consume enough water to keep the urine pale or to maintain a urine output of at least 1 L/d.

Patients must be informed about these physiologic alterations and measures to compensate for them. Otherwise, instructions are simple, and ileostomy patients should live normally. A low-residue diet should be advised at least initially. Certain foods (eg, fish, eggs) may cause excessive odor or gas. Ordinary physical activity, employment, and social activities are encouraged. Bathing, swimming, sexual intercourse, and pregnancy and delivery are unrestricted.

Ileostomy Complications

Complications are reported in about 40% of patients with conventional ileostomy; about 15% require operative correction, usually minor.

Intestinal obstruction

May be due to adhesive bands, volvulus, or para-ileostomy herniation of bowel.

Stenosis

Circumferential scar formation at the skin or subcutaneous level is usually at fault. Stenosis may cause profuse watery discharge from the ileostomy. Treatment requires a minor local procedure to release the scar.

Retraction

The stoma should protrude 2–3 cm above the skin level to avoid leakage beneath the ileostomy pouch. A flush or retracted stoma functions poorly and should be revised.

Prolapse

Uncommon if the mesentery has been sutured to the parietal peritoneum.

Para-ileostomy abscess and fistula

Perforation of the ileum by sutures, pressure necrosis from an ill-fitted appliance, or recurrent disease may cause abscess and fistula.

Skin irritation

The single most common complication of ileostomy, due to leakage of ileal effluent onto the peristomal skin. Usually minor but can be severe if neglected. Treatment is directed toward the cause of leakage, usually an ill-fitted pouch. Protection of the skin by a barrier material (eg, karaya [Sterculia] gum) or a variety of synthetic products will resolve the problem. Enterostomy therapists manage these problems expertly.

Offensive odors

Odor-proof appliances, commercial deodorants placed in the appliance, and attention to diet usually control the problem.

Diarrhea

Excessive output should be reported to the physician promptly, and supplemental water, salt, and potassium should be given. Codeine, diphenoxylate with atropine, or loperamide may slow the output. Recurrent intestinal disease, bowel obstruction, or ileostomy stenosis should be looked for.

Urinary tract calculi

Uric acid and calcium stones occur in about 5–10% of patients after ileostomy and are probably the result of chronic dehydration due to inadequate fluid intake. Ileostomy is associated with lower urine pH and volume and higher urine concentration of calcium, oxalate, and uric acid than in patients with intact gastrointestinal tracts.

Gallstones

Cholesterol gallstones are three times more common in ileostomy patients than in the general population. Altered bile acid absorption preoperatively may be responsible.

Ileitis

Patients who develop inflammation of the ileum just proximal to the ileostomy usually have recurrence of their original inflammatory bowel disease. Stenosis of the stoma is another cause.
Varices Varices develop around the stoma in patients with portal hypertension. Bleeding can be troublesome.

Follow-up

In long-term follow-up of ileostomy patients, most return to their previous occupation and consider their health to be good to excellent. Continent ileostomy is preferable to conventional ileostomy in the view of some patients who have had both types of stoma.

Sexual consequences of proctocolectomy should be discussed before and after operation. Some degree of sexual impairment occurs in 10% of men after removal of the rectum. Up to three-fourths of women report dyspareunia or reduced orgasmic sensation in the first month after proctectomy and ileostomy but only 12% experience long-term sexual dysfunction. Infertility is more frequent among women after excision of the rectum, and cesarean delivery is necessary more often; both problems are related to pelvic fibrosis and not the ileostomy.

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