Stomas

1. Look at the site and morphology of the stoma and try to identify it.
2. Check whether it is functioning or not (presence of effluent or gas). 
3. Comment on the effluent (consistency, colour and amount).
4. Look for possible complication of the stoma (offer the removal of colostomy bag with gloved hands). 
5. Try to figure out the possible surgery patient might have undergone (look at the abdominal scar/ perineal scar).

This patient is having an end colostomy at Right Iliac Fossa (RIF). The Mucosa appears pink and healthy. It is functioning and contains moderate amount of faeculent effluent with gas. There is no evidences of bleeding or necrosis. There is a midline laparotomy scar evidencing pervious Hartman's procedure or Abdominoperineal Resection (APR). I would like to inspect for a perineal scar to differentiate it.

1. Identify the site and morphology.
2. Functioning? (Effluent or Gas?).
3. Comment on the Effluent (Consistency, Colour, Amount).
4. Complications? (Offer removal of the bag). 
5. Possible surgery? (Look at the abdominal scar/Perineal scar).

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1. What are the types of stomas?

1. Input and Output stomas 

2. Temporary and Permanent stomas.
3. According to the site.

a. Gastrostomy.

b. Jejunostomy.

c. Ileostomy.

d. Ceacostomy.

e. Colostomy.

i. Ascending colostomy.

ii. Transverse colostomy.

iii. Descending colostomy. 

iv. Sigmoid colostomy.

f. Urostomy.

2. What are the morphological types of colostomies?

1. End colostomy.
2. Loop colostomy.
3. Double barrel colostomy.

3. What are the indications for colostomy/ileostomy?

1. Permanent, End colostomy - in Abdomino-perineal resection (APR).
2. Temporary, End colostomy - in Hartman's procedure.
3. Permanent, End ileostomy - in Panproctocolectomy in colitis ulcerative (UC) or FAP. 
4. Loop ileostomy (Defunctioning ileostomy) - to protect a distal anastomosis (eg: AR).

4. How do you differentiate a colostomy from an ileostomy?

1. Colostomy is flushed with skin whereas ileostomy is a spout. 

2. Colostomy is usually located in LIF whereas ileostomy is in RIF. 

3. Colostomy effluent is faeculent whereas in ileostomy effluent is liquid.

5. What are the factors to consider when selecting the stoma site?

1. Easily accessible.

2. At least 5cm away from the umbilicus. 

3. Should not overlie the skin creases and waist line of clothes.

4. Should not overlie past surgical scars. 

5. In a place where the stoma bag does not come in contact with anterior superior iliac spine.

6. What are the complications of colostomy?

Early

1. Bleeding

2. Necrosis

3. Suture detachment

Late

1. Stenosis

2. Retraction

3. Prolapse

4. Parastomal herniation

5. Fistula formation

6. Skin excoriation

7. Stoma diarrhoea