Approximately 10-15% of patients with colorectal cancer require a colostomy. Colostomy refers to a surgical procedure where a portion of the large intestine is brought through the abdominal wall to carry stool out of the body. During a colostomy, a surgeon will create an opening between the intestine and the abdominal wall. This opening is referred to as a stoma. The stoma is then attached to the outside of the abdomen so that waste materials can exit the body.
Colostomies may be temporary or permanent. Temporary colostomies are created to divert stool from injured or diseased portions of the large intestine, allowing rest and healing. Permanent colostomies are performed when the distal bowel (bowel at the farthest distance) must be removed or is blocked and inoperable.
Cancer patients with colostomies are faced with several issues, including the management of pouches, dietary adjustments, skin care, and pain management.
Selecting and Managing a Pouch
One of the primary issues with a colostomy is the selection of a pouch. The type of pouch used to collect stool is important because it protects the skin surrounding the stoma and effectively contains stool, which is essential to quality of life. Pouches may be flexible, rigid, flat or convex. In addition, pouches may have features such as skin barriers, gas filters, belts, or tape borders. With so many options available, patients may find it helpful to consult with a nurse who specializes in caring for patients with colostomies.
When using a pouch, it is important to:
Select a pouch that is appropriate for the type of diversion. Depending on the portion of the intestine where the diversion is created, the drainage may be thick or thin and may consist of high or low volumes of output. Pouches may be closed-ended or drainable. Closed-ended pouches are designed for patients with low output diversions who prefer to remove and change the pouch rather than empty it. These pouches may also be good for patients with poor manual dexterity, as they are easier to use than pouches with a closure system. Drainable pouches are more common for patients with fecal diversions and are required for patients with high volumes of output.
Match the pouching system to the contours of the abdomen and the height of the stoma. It is critical to maintain the pouch seal to the skin around the stoma. In many cases, the patient will be evaluated in both a lying and sitting position to determine how the stoma is located in the abdomen and if a flexible or rigid pouch would be most effective.
Choose the appropriate pouch size. The size of the pouch must minimize the exposed skin. In general, the opening of the pouch should be about one-quarter inch larger than the stoma and provide one-eighth of an inch of clearance on each side.
Use protective skin products. Pastes, powders, and barrier rings are designed to provide protection from enzymes contained within the stool that are destructive to the skin.
Managing the Different Types of Colostomy
There are several different types of colostomy, including ileostomy, transverse colostomy, and sigmoid or descending colostomy. These procedures are performed for different reasons and each presents different management issues.
Management Strategies for Ileostomy: An ileostomy is an opening into the small intestine and typically involves removal of the colon and rectum (portions of the large intestines) because of inflammatory diseases or when there is a mass that is obstructing the colon. However, in some cases an ileostomy may be inserted temporarily to allow wound healing within the large intestine. Fortunately, the small bowel contains little bacteria and produces very little gas, so odor prevention is usually manageable with an ileostomy. Patients with ileostomies are faced with four main issues: skin care, dehydration, fiber consumption, and absorption of medications.
Skin care: Ileostomies are usually high-volume output diversions, producing 500-1000cc of output per day. The drainage from this diversion typically contains a large amount of enzymes, which makes it critical for patients to practice appropriate skin care to prevent destruction of the skin.
Dehydration: On a daily basis, patients with ileostomies may lose 250-500cc of fluids that would have normally been absorbed by the large intestines. As a result, it is important for patients to take precautions against dehydration. Patients with ileostomimes are instructed to increase their daily fluid intake by 1-2 glasses of water per day.
Fiber Consumption: Patients with ileostomies should consume a diet that is high in soluble fiber. Soluble fiber should be eaten in small amounts to prevent food blockages created by a mass of insoluble fiber. Patients with ileostomies must be able to recognize the signs of a food blockage, which include no output from the ileostomy, high-volume liquid output with a foul smell, cramping pain, distention and possibly nausea and vomiting.
Absorption of Medications: Since many medications are absorbed within the large intestines, patients with ileostomies may poorly absorb many medications. Whenever possible, patients with ileostomies should use liquid forms of medications to ensure absorption.
Management Strategies for Descending/Sigmoid Colostomy: A descending or sigmoid colostomy is typically performed when the rectum is removed. For these patients, the stool is a regular consistency and patients will usually have two bowel movements per day. Major issues for patients with descending/sigmoid colostomies include constipation (and gas and odors) and irrigation.
Constipation: Patients with descending/sigmoid colostomies must avoid constipation. Patients should drink adequate fluids and consume a high-fiber diet. Some patients may find it helpful to use bulk laxatives, such as Metamucil® or Citracel ®. Patients can create their own dietary bulk laxative by combining 1 cup of unprocessed millers bran, 1 cup of applesauce and ¼ cup of prune juice. This mixture should be consumed daily (start with 2 tablespoons) and increased by 1 tablespoon daily until soft-formed stools are produced. Acutely constipated patients may use oral laxatives to restore bowel movements.
Irrigation: Patients with descending/sigmoid colostomies may need to manage their diversion with routine irrigations of tap water to improve and regulate bowel function. This technique should be taught be a provider skilled in the care of colostomies.
Coping with Cancer Treatment and Colostomy
Cancer treatment can present additional issues for patients with colostomies.
Radiation: Radiation to the stoma may create skin damage if the pouch is removed during radiation, so minimally adhesive systems should be used until the radiation is complete. If the pouch is left intact during radiation, care should be taken to be sure that no metal component or ingredients such as zinc oxide are used.
Stomatitis: Just as patients may develop mouth sores as a side effect of chemotherapy or radiation, the stoma may also be affected by ulcerations, tenderness, and swelling. Patients are encouraged to advise their physicians of any changes that may occur to the stoma during treatment.
Effects of Pain Medication: Pain medication frequently prescribed to cancer patients often results in moderate to severe constipation. Patients may need to increase their fiber intake and fluids. Stronger remedies, such as laxatives and irrigation of the fecal diversion, may be necessary.
In summary, colostomies can present several issues for cancer patients; however, with appropriate management strategies, cancer patients can prevent complications and maintain quality of life. Patients or caregivers coping with the management of colostomies may benefit from access to organizations such as the United Ostomy Association ( www.uao.org ) for support and product information.