There are now estimated to be approximately 205 000 people in the UK with a stoma (Hodges, 2022). The cost of stoma products used in the UK in 2020 was audited by the British Healthcare Trades Association (BHTA) and was determined to be £405 million (Hodges, 2022). Therefore, it is important to ensure that NHS resources are appropriately used. To achieve this, it is necessary to understand stoma care.
A stoma is formed during surgery by bringing part of the bowel through the abdominal wall and stitching it in place on the abdomen. There are three main types of output stoma: faecal output stomas are the colostomy and the ileostomy, while the urinary output stoma is termed an ileal conduit or urostomy. Stomas can be temporary or permanent. A temporary stoma will need a second operation to reverse or close the stoma, usually several months after the initial operation. Each stoma will be discussed separately to explore reasons for formation, appearance, output, appliances, any dietary changes and potential complications.
It can be useful to revisit the anatomy and physiology of the bowel to gain better understanding of stomas. The gastrointestinal tract begins at the mouth and is where food and drinks are usually ingested. It passes towards the stomach to further break down ingested food through the aid of chemicals and the churning of the stomach wall. Once food is broken down, it will pass into the small bowel. This consists of three parts: nearest the stomach is the duodenum, the jejunum and the ileum. The job of the small bowel is to absorb nutrients and fluid that is needed in the body, with often over 4 litres being absorbed in the small bowel. While a stoma can be formed in all three parts of the small bowel, it is commonly formed in the ileum—more specifically, at the end of the ileum, before it joins the large bowel in the terminal ileum.
The large bowel, or colon, is larger in diameter than the small bowel and is shaped like a question mark, with the rectum and anus at the farthest point from the mouth. After the small bowel is the caecum, ascending colon, transverse colon, descending colon and sigmoid colon; the latter joins the rectum. The role of the colon is to thicken faeces, forming soft, sausage-shaped stools to be passed from the anus. Thickening of faeces as they travel through the colon occurs as a result of further fluid absorption of approximately another litre. Within the colon, additional sodium is also absorbed. A stoma can be formed from any part of the colon, but is commonly formed from the sigmoid or descending colon.
Stoma appliances
A stoma appliance has many different names: a ‘stoma bag’ or ‘stoma pouch’ are terms commonly used by patients. A stoma appliance is used to collect and contain the output from a stoma. Thus, there are two important parts: the adhesive and the collection component. The collection component consists of plastic, which will contain any odour. Most are covered with a soft cover that is situated next to the skin, to improve comfort when wearing the appliance and to cover the output from the stoma. In this section, there will be a filter to faecal output, which is designed to release the flatus but not odour. This filter can be covered during bathing or swimming by small adhesive covers, to prevent it from becoming wet and ineffectual. The urostomy appliance has several layers within the appliance to try and reduce the chance of urine backflowing to the top of the appliance.
The adhesive part of the stoma appliance is designed to securely adhere to the abdominal wall around the stoma. The appliance adhesive has many names, including ‘flange’, ‘baseplate’ and ‘faceplate’. To protect the skin around the stoma (peristomal skin), the aperture in the flange should be same shape and approximately 2–3 mm larger than the stoma itself (Stelton, 2019).
A stoma appliance is available as both a one-piece item or two-piece item. For one-piece products, the flange and collection components are combined (Burch and Black, 2017). Two-piece products come with a separate flange and collection component, which are then joined by a clip or an adhesive ring, depending on the manufacturer. The two-piece stoma appliances can be joined prior to application, or the flange can first be applied and secured and the collection component then attached.
Colostomy
A colostomy is formed from the colon or large bowel (Stelton, 2019). There are many reasons why a colostomy might be formed, with the most common underlying conditions being rectal cancer and diverticular disease. The colostomy will be red or pink in appearance and warm and moist to touch. A colostomy is usually situated in the left iliac fossa and is ideally minimally raised above the abdominal wall by about 5mm. The output from a colostomy is formed of faeces and flatus, with a volume of about 150–200 g daily. The colostomy appliance is sealed to collect and contain the faeces. The colostomy appliance is changed each time it becomes soiled, which is usually between three times a day and three times a week, with the most common frequency being once a day. For a colostomy formed in the proximal colon, such as ascending or transverse, the output will be looser, and a drainable appliance might be more suitable.
A person with a colostomy should maintain a healthy diet, as per NHS (2019) guidelines. It is important to consume adequate fluid and fibre to prevent constipation. For most people, that means eating fruit and vegetables each day and drinking approximately 1500 ml of fluid. Alcohol can be consumed, keeping within the recommended guidelines.
A person with a colostomy might encounter problems such as constipation, overgranulation and pancaking. Constipation in a person with a colostomy can be described as hard, dry faeces in the colostomy appliance or no output for longer than usual. Constipation cannot easily be treated for people with a colostomy by using suppositories and enemas, as it is prone to leave the colostomy before becoming effective. To address this, it is better to act preventatively through giving advice on healthy eating and adequate fluid consumption, as well as undertaking regular exercise, such as walking. If amendments to diet and routine do not resolve the issue, oral laxatives can be used effectively. It is important to recognise that if there has been a faecal blockage or impaction after laxatives are used, it is likely that more faeces than usual will pass and frequent appliance changes may be necessary. In this situation, a drainable appliance can also be useful.
Overgranulation can occur around the colostomy, most commonly at the mucocutaneous junction, where the stoma and the abdominal wall join. In appearance, overgranulation is red and is often described as a cauliflower-like, raised nodule. There is often more than one area of overgranulation. They can occur soon after surgery or many years later, and may be the result of a degree of trauma, such as rubbing of the area. These nodules can bleed and increase in size and number, causing problems with appliance adhesion. It is important to ensure that they are not a sign of cancer recurrence, which may require a biopsy. However, overgranulation is usually successfully treated with silver nitrate, applied several times a week during appliance change. This needs to be undertaken cautiously so as not to damage the mucosa of the stoma, and patients need to be reminded that the overgranulation will turn grey or black after silver nitrate is used; for most patients, this is not overly painful, but can sting. Often, multiple applications of silver nitrate are needed and overgranulation can recur.
Pancaking is described as faeces of a consistency that do not drop into the colostomy appliance, but instead push under the flange next to the skin. Pancaking can lead to skin damage if faeces are left next to the skin for extended periods of time. Pancaking can also result in faeces leaking onto clothes. Pancaking is the result of the consistency of the faeces; therefore, by making the faeces thicker or looser, the problem may resolve. This can be achieved by alterations to diet, such as taking an extra glass of fruit juice each day. Alternatively, the filter can be covered with the small adhesive filter cover to retain a small amount of air within the colostomy appliance, keeping the inside edges of the colostomy appliance apart. The edges can also be kept apart by adding a small, crumpled piece of tissue to the appliance prior to adhering it to the abdominal wall.
Ileostomy
An ileostomy is formed from the ileum or small bowel. There are many reasons that an ileostomy might be formed, with common underlying conditions including inflammatory bowel disease or rectal cancer. In appearance, the ileostomy will be red or pink, and it will be warm and moist to touch. An ileostomy is usually situated in the right iliac fossa and is ideally formed into a small spout of about 25mm (Stelton, 2019). The output from an ileostomy is loose faeces and flatus, and the output can be approximately 500–800 ml. The appliance will be drainable and sealed with a Velcro-type fastening. It will fill throughout the day and will need to be emptied approximately 4–6 times each day when it is between a third and halfway full. The ileostomy appliance needs to be changed every 1–3 days.
A person with an ileostomy should maintain a healthy diet, being careful to chew their food. As the diameter of the small bowel is physically smaller than that of the large bowel, it can become blocked. It is also important to remember that as there is less opportunity for the body to absorb fluid and sodium, this needs to be added into the diet. Thus, most people with an ileostomy should drink 1500–2000 ml each day and add a little extra salt to meals, unless there are any medical reasons not to do so. It is important to still consume fruit and vegetables for the vitamins that they provide, but these should be taken with caution in the first 2 months after surgery, with a gradual introduction to the diet. The best way fruit and vegetables are tolerated is when well-cooked or a tinned version. Raw fruit and vegetables are more likely to cause problems, such as a food bolus blockage; these should be eaten in small amounts and chewed well.
A person with an ileostomy might encounter certain problems, such as a food bolus blockage, skin damage or high faecal output. A food bolus blockage can occur because of poorly chewed food, particularly fibrous foods that are difficult to digest, such as sweetcorn or mushrooms. A food blockage will present with different symptoms, depending on the severity of the blockage. Initially, there will be a reduced or no output from the stoma. As the symptoms progress, there may be nausea and abdominal discomfort as a result of the increased amount of faeces building behind the blockage and the contractions of the bowel trying to move the faeces forward. Progression of symptoms can include increased abdominal pain and vomiting. In the early stages of a blockage, it might be possible to achieve resolution through conservative measures. In the early stages, it is advisable to stop eating and to increase the volume of oral fluids taken to try and ‘flush’ the food bolus blockage into the ileostomy appliance. It can be possible to increase mobility or use a warm bath to try and relax the abdomen and release the blockage. Once the blockage is removed, it is normal for the appliance to fill more than usual. If pain increases or vomiting occurs, the person needs to attend A&E. The most likely treatment in hospital will be intravenous fluids to provide hydration and a nasogastric tube to drain the stomach and prevent vomiting. It is uncommon for this approach to be ineffective and very rare for surgery to be undertaken.
The peristomal skin is at risk of damage, because of the enzymes present within the ileostomy output that can literally digest the peristomal skin. In a Swedish study by Marinez et al (2021), skin problems were one of the top three most common problems occurring in the first year following stoma formation; this is likely to apply to the UK and other countries. To prevent the skin from being damaged, regular changing of the appliance is critical. It is important to address any appliance leakages as soon as possible to reduce time that the faeces are in contact with the peristomal skin. Ideally appliance leaks should be prevented, which can be difficult in people with skin creases or uneven peristomal skin surfaces. To prevent leaks in this scenario, it can be useful to ‘fill’ any creases or skin dips. This can be achieved using a stoma seal (washer or donut), either around the stoma or broken into fragments and formed into the shape and size of the skin crease or dip. The alternative can be the use of a small amount of stoma paste to fill the gap. It may be necessary to use a seal and paste together in complicated scenarios, to fill the creases and prevent appliance leakage and skin damage.
Regarding people with a faecal output of over 1 litre each day, if this is a recognised long-term issue for that person, they will need to adopt measures to protect their peristomal skin. This may include the use of a barrier film, applied during the changing procedure after the peristomal skin is cleaned and dried and prior to adhering a new appliance. It might be necessary to use a stoma seal to add additional adhesion to the appliance to prevent the proteolytic enzymes from damaging the flange and the peristomal skin. If the high faecal output is new, it needs to be investigated, as it might be because of an infection and require treatment with antibiotics.
Urostomy
A urostomy is commonly formed from a small segment of ileum, giving the name ileal conduit. A urostomy is the least commonly formed stoma and might be formed for a bladder cancer where the bladder needs to be removed (Stelton, 2019). A small bowel segment is used to form the urostomy at one end on the abdominal wall and the other end is oversewn, with the two ureters attached. In appearance, the urostomy will be red or pink, and warm and moist to touch. A urostomy is usually situated in the right iliac fossa and is ideally formed into a small spout of about 25 mm; therefore, in appearance, it will resemble an ileostomy. However, the output from a urostomy is urine and a small amount of mucus from the bowel conduit, with a usual output of about 1200 ml per day. The appliance used for a person with a urostomy is drainable and fastened with a tap or bung to allow the collected urine to be emptied. A urostomy needs to be emptied 4–6 times a day when a third to halfway full. It is common to use a leg or night bag attached to the bottom of the urostomy appliance at night. The urostomy appliance is changed every 1–2 days.
A person with a urostomy should maintain a healthy diet, being careful to consume about 2 litres of fluid each day. There is anecdotal evidence that drinking cranberry juice each day will help to keep mucus production at a minimal level.
If urine becomes cloudy or malodourous or there is increased mucus production, this is likely to indicate a urinary infection. It is important to remember that as there is no bladder in-situ, this infection is an upper urinary tract infection and needs prompt investigation to determine if antibiotics are necessary. To test the urine, it is important not to use a specimen from the urostomy appliance but instead to take a sample from the urostomy itself. This can be achieved by careful intubation of the urostomy with a urinary catheter and collection of urine as it drips from the catheter. It is also important to ensure that adequate oral fluids are taken.
Discoloured urine can occur for several reasons. If the urine is concentrated, it can indicate a level of dehydration that needs to be addressed by increasing oral fluid intake. However, some medication or foods, such as beetroot, can change the colour of urine, which is not dangerous. If there is blood detected in the urine, this is not normal and requires investigation.
Activities with a stoma
People with a stoma may assume that they will not be able to participate in activities, but this is not the case. There is growing evidence that increased mobility after surgery is beneficial. While there is an increased risk of development of a parastomal bulge or parastomal hernia after stoma formation, this can be mitigated against by performing abdominal strengthening exercises (Russell, 2019). Exercises can be gradually commenced after surgery, starting with walking. For heavier activities, such as gardening, it can be useful to wear a support belt/garment. A parastomal hernia is common, with possibly one in three people developing one (Pearson et al, 2020), so it is ideal to try and prevent them from occurring.
Quality of life
Research shows that quality of life after stoma formation is good (David, 2016). Changes do need to be made, for example, to accommodate the appliance change into the daily routine, but this occurs within a few months for most people. However, if people are struggling with coming to terms with having a stoma, it can be useful to refer them for counselling. It is also important to recognise that having problems with their stoma, such as appliance leakage, will reduce quality of life (Claessens et al, 2015); therefore, this needs to be addressed as a priority (Goldstine et al, 2019). In particular, appliance leakage needs addressing if it is a regular occurrence; review by the stoma specialist nurse may be necessary, but many community nurses can assist with this issue. While it is also important to think of the financial implications if product usage increases for a patient, increased usage also needs to be considered if leakage is occurring to try and resolve the issue. This is important as patients may not feel able to seek help for stoma issues. More importantly, they may have a reduced quality of life that the community nurse might be able to easily improve by resolving their stoma-related issue.
Conclusion
Having a stoma means some changes to lifestyle are necessary, and there are several complications that can occur. However, with care and nurse intervention if required, a good quality of life is achievable. Careful appliance change to prevent peristomal skin damage, eating a healthy, balanced diet and chewing food well, alongside consuming appropriate oral fluid volumes, will help to maintain health. However, the community nurse is well-positioned to assist with issues if they do arise.
