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