Ostomy complications

Background

• Ostomies (colostomy, ileostomy, urostomy) are common, and patients frequently present to the ED with complications
• Types: colostomy (most common), ileostomy (higher output, more dehydration risk), urostomy
• Key EM pearl: ileostomy patients are at high risk for dehydration and electrolyte derangements due to high-volume liquid output

Complications

Parastomal Hernia

• Most common long-term complication
• Bulge around stoma that may reduce spontaneously
• If reducible and nontender: outpatient surgery referral
• If incarcerated/strangulated: nausea, vomiting, non-functioning stoma → emergent surgical consultation

Stomal Prolapse

• Telescoping of bowel through stoma — can appear dramatic but is often reducible
• Apply sugar to edematous stoma to reduce swelling, then gently reduce
• Surgical consultation if unable to reduce or if signs of ischemia (dusky/black color)

Stomal Retraction/Stenosis

• Stoma retracts below skin level or narrows
• Difficult appliance management, obstruction risk
• Surgical referral for revision

Obstruction

• High-output stoma that suddenly stops functioning
• Abdominal distension, nausea/vomiting, cramping
• Abdominal X-ray or CT to evaluate
• Management similar to small bowel obstruction: NPO, NG tube, IV fluids
• Surgical consultation

Peristomal Skin Breakdown

• Irritant contact dermatitis from effluent exposure (especially ileostomy — alkaline output)
• Candidal infection (satellite lesions)
• Allergic contact dermatitis (from appliance adhesive)
• Management: barrier creams/powders, proper appliance fitting, treat infection

Stomal Ischemia/Necrosis

• Stoma appears dark, dusky, or black
• If only superficial: observation with close follow-up
• If necrosis extends below fascia: emergent surgical consultation (risk of peritonitis)

Dehydration / Electrolyte Derangements

• Especially with ileostomies — can lose 1-2L/day
• High output: >1.5 L/day warrants evaluation
• Risk of hyponatremia, hypokalemia, metabolic acidosis, AKI
• Aggressive IV fluid resuscitation, electrolyte replacement

Bleeding

• Minor stomal bleeding (trauma from appliance): direct pressure, silver nitrate
• GI bleeding through stoma: evaluate as any GI bleed — CBC, type and screen, GI consultation

Infection

• Peristomal cellulitis or abscess
• Antibiotics; I&D if abscess present

Evaluation

• Stomal assessment: color (should be pink/red), output, surrounding skin
• BMP: electrolytes, renal function (especially ileostomy patients)
• CBC if concern for bleeding or infection
• Abdominal X-ray or CT if obstruction or peritonitis suspected
• Stool studies if infectious diarrhea suspected (high-output colostomy)

Disposition

• Admit: obstruction, stomal necrosis below fascia, incarcerated hernia, significant dehydration/AKI, GI bleeding
• Discharge: reducible prolapse, minor skin breakdown, mild dehydration corrected in ED, minor bleeding
• Ostomy nurse referral for appliance issues and skin management

See Also

• Post-surgical complications
• Small bowel obstruction
• G-tube complications