UOAA 2009 Conference Workshop “Ask the Doctor” by Jaime Bohl M.D

Dept. of Colon & Rectal Surgery
Ochsner Clinic Foundation, New Orleans, LA
As Reported by Wendy Lueder

Ileostomies are one of three different types of ostomies; the others being colostomies and urostomies. Ileostomies are a surgically created opening between the small intestine and abdomen. Colostomies are a surgically created opening between the large intestine and abdomen. Urostomies are a surgically created pathway using a small portion of the small intestine from the kidney’s ureters to the abdomen. Ileostomies and urostomies, unlike colostomies, have a continual liquid output. Ileostomies have an output of approximately 800cc per day and are less odorous than colostomies and if any output comes into contact with the skin, severe irritation occurs from the bile salts and acidic digestive enzymes it contains. Output from a colostomy or urostomy doesn’t destroy the skin around the stoma in the same way. Colostomies have a more solid 250cc intermittent output.

Ostomies first appear in history in 1757 when Lorenz Heister spontaneously developed one in France (don’t ask me how) and actually lived 30 more years using a leather pouch. Pouches have come a long way: In the 1940’s model T inner-tubes were used. The use of tuna cans and bread bags has been reported.

In the 1950’s Dr. Rupert Turnbull accidentally invented Karaya powder rings when he noticed that a jar of karaya powder which happened to spill on his wet hands was difficult to remove. That was the birth of the modern surgical appliance.

Ileostomies are indicated (don’t you love medical speak?) from inflammatory bowel disease, cancer, diverticulitis or incontinence. Because of the unusually large liquid output dehydration is a real danger. Without surgery 200cc per day is normal. Immediately after surgery 1000 to 1500cc per day may occur. For the matured ileostomate 500 to 800cc are normal. Heat, exercise, illness such as gastroenteritis, Crohn’s, or partial obstruction can cause dehydration so it is very important to get immediate medical attention if dehydration occurs. Chronic dehydration leads to kidney stones since urine becomes acidic and uric acid kidney stones may form. Ileostomates absolutely must increase fluid intake. NaHCO3, a different kind of kidney stone from normal is what is usually formed.
Vitamin B12 deficiency is also a potential danger for ileostomates as B12 is absorbed in the terminal ileum which may have been surgically removed. The side effects of B12 deficiency are tingling hands and feet as well as anemia. This can be easily treated with monthly B12 injections.

The placement of stoma is of extreme importance as it greatly effects the ostomate’s quality of life. If too big it can cause herniation; it cannot be located too near the hip bone and must be 2 to 3 cm up from skin to keep effluent off the skin. An “end” stoma is used if surgery is permanent; a loop stoma is created if the surgery is temporary and will be reversed. Complications occur more frequently if the surgery is performed from emergency conditions with an unplanned stoma; obesity; older age; or from increased dimples in the skin. 80% of ileostomates experience skin problems: many result from improper placement near bony prominences, skin folds, scars, obesity or from flush stomas. Caustic enzymes from output that makes contact with the skin destroy the keratin layer of epidermis.
Another complication is stoma retraction after swelling from surgery goes down: Using a belt or a convex skin barrier helps, however pressure necrosis may be caused by wearing a too tight belt.

Leakage of appliance can be caused by poor adhesion due to allergic reactions to adhesives, tape, skin barriers or candida yeast infections which are the most common type of infection. Mycostatin topical powder clears yeast infections but should never be used any longer than absolutely necessary as negative side effects can occur. Pyoderma, from Crohn’s is hard to treat and causes painful ulcers. Crohn’s disease may even occur in stoma. Stoma necrosis (purple colored stoma) needs stomal revision. Stenosis, narrowing of skin around stoma needs to be treated with surgery but can be done with a local repair, not back through the abdomen.

Prolapse, often associated with hernia, may occur and can be very unnerving for the ostomate. Repair is not urgent unless the bowel becomes gangrenous. It may be reducible with surgeons’ finger pushing the stoma back in. If your stoma remains protruded, get help right away.

Obstructions: symptoms are; no output, abdominal distention: nausea and vomiting. You need urgent attention. Obstructions can occur from swallowing a diagnostic camera: from food blockage, high fiber foods, x-ray contrast material ingestion or Crohn’s stoma stenosis (narrowing of the stoma).

Parastomal Hernias are a common problem for ostomates. The hernia may allow loops of bowel to push up. Hernias may or may not need surgical intervention and many times are controlled by merely wearing a hernia belt (see Nu-Hope Labs in previous article). However, sometimes they may be symptomatic and need emergency attention. The mesh that’s often used for hernia repairs is more successful if it is not synthetic. Synthetic meshes tend to get infected. Alloderm mesh has been more successful, getting fewer infections. It is very strong and is made from cadavers.

The necessary surgical repair may be done locally at the stoma site or your stoma may need to be relocated. Ostomates have a 4-11% chance of having a hernia, a 1-3% chance of prolapsed (your stoma protruding too far), a 4-9% chance of having an obstruction and a 1-3% chance of a stomal retraction.

Doctor Bohl strongly suggests that if you have some rectum left, functionally it may not be advisable to reconnect due to quality of life issues such as partial incontinence.

If you’re an ileostomates your output is very acid containing bile salts and enzymes. If your skin becomes irritated from this output try applying Maalox which will neutralize the acid then wash off the Maalox completely before applying your skin barrier wafer to your clean and completely dry skin. Use Maalox instead of Mylanta or other brands of antacids as it contains fewer flavorings and extra ingredients.

Ileostomates may experience too low b12 levels as b12 is absorbed in an area of your intestine that may have been surgically removed. Have your doctor check your levels before starting any b12 supplements as it is highly probable you don’t have this problem.

When asked of her opinion of having both a GI surgeon and a plastic surgeon present to reduce the amount of scarring during ostomy surgery, she said “By all means. That’s a good idea.”
Dr. Bohl was well received by the entire large audience and I thank her for her input. Any errors in this transcript are totally due to my misunderstanding so please, always consult our own medical professionals before taking any of this advice.