**5. Illustration of more common ostomy complications**

The more common type of ostomy complications are:


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

7.Necrosis

*Gastrointestinal Stomas*

III.Pseudoverrucous lesions

IV.Bacterial and fungal infections

• Cramps lasting more than 2 or 3 h

• Continuous nausea and vomiting

• A cut in the stoma

• Injury to the stoma

*4.4.2 When the ostomate should call the doctor or ostomy nurse*

• No ostomy output for 4–6 h with cramping and nausea

• Bad odor lasting more than a week (this may be a sign of infection.)

• A lot of bleeding from the stoma opening (or a moderate amount in the pouch

The complication occurrence in intestinal stomas might be related to factors such

as lack of demarcation of the skin site, surgical technique itself, or to postoperative care. Each type of complication deserves a different treatment approach. For sure a prompt intervention is advisable to avoid or to minimize the complication

• Severe watery discharge lasting more than 5 or 6 h

that you notice several times when emptying it)

• Continuous bleeding where the stoma meets the skin

**5. Illustration of more common ostomy complications**

The more common type of ostomy complications are:

• Bad skin irritation or deep sores (ulcers)

• Unusual change in your stoma size or color

• Anything unusual going on with your ostomy

**42**

occurrence.

1.Mucosal edema

4.Ostomy prolapse

3.Retraction

6.Hematoma

2.Peristomal dermatitis

5.Mucosal/skin detachment


The following pictures are illustrative examples of these complications.

#### **5.1 Mucosal edema**

On the practical settings, edema may not be considered as a true complication as it can result from a normal physiological response after manipulation of intestinal loop. It is normal for the stoma to be edematous postoperatively looking swollen within 4–6 hours. The swelling progresses for the first 2 days and by the fifth day subsides markedly. The edema continues to decrease for the first 6–8 weeks after surgery. While edematous, the stomal mucosa is pale and translucent and the stoma tissue remains soft. The main approach to treat an ostomy edema is observation plus the care with manipulation and correct application of pouch, to avoid mechanical trauma. It should be reminded that if the edema is caused by technical problems, e.g., a narrowed abdominal wall opening, it may be advisable to reoperate in order to correct the problem [11] (**Figure 2**).

#### **5.2 Peristomal dermatitis**

Peristomal dermatitis is the most common stoma complication. It is characterized by skin irritation around the stoma, caused by several factors: irritation of the skin by feces, contact or products used in ostomy care which may be corrosive, contact allergy due to the nature of the chemical component of the pouch in contact with the skin, mechanical infection by pouch withdrawal-induced trauma or by compression of the fixation belt, and bacterial or fungal skin infection caused by humidity and effluent from gut making the peristomal skin more vulnerable to microorganisms' proliferation. The most common symptoms are itching, burning sensation, and pain. Diabetic, immunocompromised, and long-term use of antibiotics increase the risk of infectious dermatitis in patients with intestinal stomas [12, 13] (**Figure 3**).

#### **Figure 2.**

*Ileostomy edema. Usual appearance; (B) care to apply the bag avoiding trauma. The stoma measurement selected for the pouching system should allow for an opening 1/8 inch to prevent stoma necrosis.*

#### **Figure 3.**

*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).*

#### **5.3 Retraction**

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 irritant dermatitis [11].

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

**45**

**Figure 4.**

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

**5.4 Prolapse**

emergency as it can lead to peritonitis (**Figure 4**).

fixation of the bowel to the abdominal wall [14].

of intestinal transit [15] (**Figure 5**).

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

**5.5 Mucocutaneous detachment**

should be indicated when a good pouching seal cannot be obtained and skin irritation persists. It should be reminded that complete circumferential mucocutaneous separation accompanied with stomal retraction below the fascia may be a surgical

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

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

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 should be indicated when a good pouching seal cannot be obtained and skin irritation persists. It should be reminded that complete circumferential mucocutaneous separation accompanied with stomal retraction below the fascia may be a surgical emergency as it can lead to peritonitis (**Figure 4**).
