**5.4 Prolapse**

*Gastrointestinal Stomas*

**5.3 Retraction**

**Figure 3.**

A stoma normally protrudes slightly above the skin level being more evident in ileostomies than in colostomies. A retraction of the stoma occurs when the stoma lays flat to the skin or below the skin surface level. Retraction has been reported to occur in as many as 10–24% of all ostomates, can be partial involving the skin and subcutaneous tissue or complete when the stoma is below the level of the fascia, can occur early or late after ostomy, and may result from a poor surgical stoma construction with consequent exteriorization of intestinal loop under tension, insufficient stomal length, poor fixation of the loop to the abdominal wall, or lack of ostomy support. It can also be secondary to abdominal structure anomalies such as thick abdominal wall related to edema, distention, or obesity. The premature removal of the loop device to support the intestine outside the abdominal wall may also contribute to this complication as well as the later scar formation secondary to healing of a mucocutaneous separation or of a necrotic stoma or even chronic peristomal irritation that healed with scar or adhesion at the mucocutaneous junction. The retraction can become problematic as it can affect the fit of the stoma bag and cause leaks, which can lead to sore and broken skin. This can be rectified by using a stoma bag with a convex wafer to push the stoma forward, an ostomy belt to help support the stoma, and/or barrier rings or a barrier paste to help keep the output off the skin. The depth of retraction may increase with sitting and can vary with peristalsis. Patients with retracted stomas present with effluent undermining the pouching system, persistent leakage, shortened pouch wear time, and resultant

*Peristomal dermatitis. Irritation caused by the effluent in an inadequate pouch adaptation to the skin allowing the prolonged feces/skin contact (A) and an early pouch detachment (B). Blister at the adhesive area in the periphery of pouch resin itself (C). Dermatitis caused by both pouch resin and peripheral adhesive (D).* 

*Dermatitis due to contact of feces with skin (E). Fungal dermatitis (F).*

The proper care will depend on a close observation of peristomal area, to prevent worsening of the retraction. The goal of managing a retracted stoma is to maintain a secure seal between the pouch and the skin. Conservative treatment with convex devices attached to the belt and protective skin pastes to fulfill spaces and leveling the interface skin/stoma may solve most cases, but surgical revision

**44**

peristomal irritant dermatitis [11].

Prolapse is the term used to describe the telescoping out of the bowel through the stoma. As a consequence the stoma lengthens and becomes more susceptible to abrasion or infection. Prolapse can be partial or complete, and either the distal or the proximal segment of the loop ostomy may prolapse being the distal portion of the bowel the most frequent site to prolapse. The etiology can involve stoma construction difficulties including a weak abdominal wall with poorly developed fascial support; creation of excessively large opening in the abdominal wall; positioning the stoma out of the rectus abdominal muscle; postoperative increase of the abdominal pressure due to obesity, cough, or pregnancy; bowel edema; and inadequate fixation of the bowel to the abdominal wall [14].

Clinically the prolapse increases the size and the length of the stoma and makes the patient's ability to conceal the stoma beneath clothing difficult. Also the edematous stoma bleeds and is more prone to trauma. A prolapsed stoma could also become obstructed making it impossible for feces to pass through what can lead to ischemia and alteration of the color that appears purple or cyanotic. Stomal irritation, bleeding, necrosis, and gangrene of the distal end of the prolapsed stoma may be seen in chronic prolapse. Conservative management includes tender manual reduction of the prolapse, appliance of a hernia type to exert a mild compression, cold dressing to induce vasoconstriction, use of sugar to induce osmotic force to decrease the amount of liquid into the intestinal layers, and ostomate lying down position. The goal of care is to provide a leak-proof pouching system applied while the patient is supine and the prolapse reduced. Surgical correction of prolapse is indicated for definitive ostomies with prediction of long permanence time and involves resection of the prolapse and stoma reconstruction. Temporary prolapse is best treated at the time of reconstruction of intestinal transit [15] (**Figure 5**).

### **5.5 Mucocutaneous detachment**

Mucocutaneous detachment is the separation of the stoma from the peristomal skin. It can be partial with area of separation shallow or deep or circumferential. Usually it is caused by factors such as (a) secondary to retraction or necrosis; (b) sequel of poor healing from an underlying disease process, more commonly in

**Figure 4.** *Ostomy retraction with light (A) and severe inflammatory reaction.*

#### **Figure 5.**

*Stoma prolapse. Note the abnormal length of the stoma. If left untreated the ostomate is more susceptible to abrasions or infection.*

the immunocompromised patient related to malnutrition, corticosteroid therapy, diabetes, infection, or post-radiation therapy that result in superficial infection and poor healing; and/or (c) iatrogenic, e.g., creating an oversized opening in the skin when forming the stoma or excessive tension on the suture line, causing a separation of the mucocutaneous junction in the immediate postoperative phase of healing. The ostomate may complain of pain or burning. Assessing the tissue type at the base of the separation often reveals fibrin slough that produces mild to moderate amount of drainage. Stool or urine draining from this site may indicate a fistula. The treatment is conservative consisting of cleaning the wound and use of calcium alginate and hydrofiber. Antibiotics may be indicated for superficial detachment until completion of the healing process. In cases of mucocutaneous separation extending to below the fascia, surgery may be necessary to avoid contamination of the abdominal cavity and peritonitis [11] (**Figure 6**).

#### **5.6 Bleeding and hematoma**

The abundant vascularization of the stoma with delicate blood vessels near to the top facilitates bleeding easily. Spots of blood are not a cause for alarm. Cleaning around the stoma as you change the pouch or skin barrier may cause slight bleeding. If the bag has rubbed around the stoma or the blood comes around the edges while the stoma is being cleaned might not be a cause for concern. However if the bleeding is coming from inside the stoma, then it is important to contact your stoma nurse or your doctor for evaluation. The bleeding originating at the mucosal surface will usually stop quickly.

Light bleeding that does not stop spontaneously or excessive bleeding from the stoma usually at the mucocutaneous junction is more frequent in the immediate postoperative period, although it can also occur later. Bleeding may occur due to inadequate hemostasis during stoma construction, portal hypertension, trauma, underlying disease, and because of some medications, such as prolonged use of analgesic anti-inflammatory drugs, blood thinners, and chemotherapy. A correct diagnosis is mandatory to differentiate the mucosal mild trauma-associated bleeding during a pouching system change from other causes that may need even a surgical approach. The adequate treatment will depend on the etiology of bleeding.

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**5.7 Necrosis**

**Figure 7.**

**Figure 6.**

*Intestinal Ostomy Complications and Care DOI: http://dx.doi.org/10.5772/intechopen.85633*

If the bleeding persists and is superficial and does not stop spontaneously, cauterization, suture placement, topical hemostatic agents (silver nitrate), or direct pressure are required procedures. Frank bleeding presenting as blood that runs down the abdominal wall requires immediate notification of the surgeon. The surgeon removes sutures, lifts the mucosa, secures the vessel with fine forceps, and ligates the bleeder. Portal hypertension induces varices around the stoma resulting in bleeding from the mucocutaneous junction. If severe, it may require sclerotherapy or portosystemic shunting. The most common cause of pharmacological bleeding is the adverse effect of prolonged use of analgesic anti-inflammatory drugs. When bleeding occurs in the late PO period, it may be associated with incorrect use of the ostomy pouch or trauma that can happen following practice of aggressive sports, for example. The management includes the use of compression with a cold dressing. A transparent plastic pouch should be used to permit a direct observation of the stoma

*Mucocutaneous detachment. (A) Usual appearance and (B) mucocutaneous separation due to peristomal infection.*

*Bleeding in a mucocutaneous detachment (A) and hematoma at the stoma fixing suture (B).*

Necrosis may occur when the blood flow to or from the stoma is impaired or interrupted, resulting in severe tissue ischemia with impairment of stoma viability or tissue death. Initially the mucosa turns pale evolving to a purple, brown, and black color. The consistency becomes soft or hard and dry with loss of the characteristic brightness of a normal mucosa. The causes for stoma necrosis are extensive

allowing quick detection of bleeding or hematoma [15] (**Figure 7**).

*Intestinal Ostomy Complications and Care DOI: http://dx.doi.org/10.5772/intechopen.85633*

#### **Figure 6.**

*Gastrointestinal Stomas*

**Figure 5.**

*abrasions or infection.*

the immunocompromised patient related to malnutrition, corticosteroid therapy, diabetes, infection, or post-radiation therapy that result in superficial infection and poor healing; and/or (c) iatrogenic, e.g., creating an oversized opening in the skin when forming the stoma or excessive tension on the suture line, causing a separation of the mucocutaneous junction in the immediate postoperative phase of healing. The ostomate may complain of pain or burning. Assessing the tissue type at the base of the separation often reveals fibrin slough that produces mild to moderate amount of drainage. Stool or urine draining from this site may indicate a fistula. The treatment is conservative consisting of cleaning the wound and use of calcium alginate and hydrofiber. Antibiotics may be indicated for superficial detachment until completion of the healing process. In cases of mucocutaneous separation extending to below the fascia, surgery may be necessary to avoid contamination of

*Stoma prolapse. Note the abnormal length of the stoma. If left untreated the ostomate is more susceptible to* 

The abundant vascularization of the stoma with delicate blood vessels near to the top facilitates bleeding easily. Spots of blood are not a cause for alarm. Cleaning around the stoma as you change the pouch or skin barrier may cause slight bleeding. If the bag has rubbed around the stoma or the blood comes around the edges while the stoma is being cleaned might not be a cause for concern. However if the bleeding is coming from inside the stoma, then it is important to contact your stoma nurse or your doctor for evaluation. The bleeding originating at the mucosal surface will usually stop quickly. Light bleeding that does not stop spontaneously or excessive bleeding from the stoma usually at the mucocutaneous junction is more frequent in the immediate postoperative period, although it can also occur later. Bleeding may occur due to inadequate hemostasis during stoma construction, portal hypertension, trauma, underlying disease, and because of some medications, such as prolonged use of analgesic anti-inflammatory drugs, blood thinners, and chemotherapy. A correct diagnosis is mandatory to differentiate the mucosal mild trauma-associated bleeding during a pouching system change from other causes that may need even a surgical approach. The adequate treatment will depend on the etiology of bleeding.

the abdominal cavity and peritonitis [11] (**Figure 6**).

**5.6 Bleeding and hematoma**

**46**

*Mucocutaneous detachment. (A) Usual appearance and (B) mucocutaneous separation due to peristomal infection.*

**Figure 7.** *Bleeding in a mucocutaneous detachment (A) and hematoma at the stoma fixing suture (B).*

If the bleeding persists and is superficial and does not stop spontaneously, cauterization, suture placement, topical hemostatic agents (silver nitrate), or direct pressure are required procedures. Frank bleeding presenting as blood that runs down the abdominal wall requires immediate notification of the surgeon. The surgeon removes sutures, lifts the mucosa, secures the vessel with fine forceps, and ligates the bleeder. Portal hypertension induces varices around the stoma resulting in bleeding from the mucocutaneous junction. If severe, it may require sclerotherapy or portosystemic shunting. The most common cause of pharmacological bleeding is the adverse effect of prolonged use of analgesic anti-inflammatory drugs. When bleeding occurs in the late PO period, it may be associated with incorrect use of the ostomy pouch or trauma that can happen following practice of aggressive sports, for example. The management includes the use of compression with a cold dressing. A transparent plastic pouch should be used to permit a direct observation of the stoma allowing quick detection of bleeding or hematoma [15] (**Figure 7**).

#### **5.7 Necrosis**

Necrosis may occur when the blood flow to or from the stoma is impaired or interrupted, resulting in severe tissue ischemia with impairment of stoma viability or tissue death. Initially the mucosa turns pale evolving to a purple, brown, and black color. The consistency becomes soft or hard and dry with loss of the characteristic brightness of a normal mucosa. The causes for stoma necrosis are extensive tension on the mesentery, excessive stripping of the mesentery, sutures too narrowly spaced, or constricting sutures. It also can result from interruption of blood flow secondary to embolization or because of abdominal structure anomalies such as thick abdominal wall secondary to edema, distention, or obesity. A higher rate of necrosis has been reported in obese and acutely ill patients.

Observation in cases of superficial or partial (less than one third of circumference) mucosal necrosis is the best approach. Debridement of the necrotic area can define the extension and deepness of necrosis. If the process compromises the whole intestinal wall or extends beyond the aponeurotic plan, a surgical intervention is indicated through the stoma opening or through the main surgical wound if a laparotomy had been performed. The use of two-piece pouch facilitates the daily observation of the stoma with no need of withdrawal of the skin attached piece. Postoperative nursing assessment and management also help prevent potential impairment of a good blood supply to the stoma [11, 16] (**Figure 8**).
