Colostomy, Colitis and Ileostomy

Colostomy

What is a Colostomy?

A colostomy is an opening in the skin of the abdomen where the skin is actually connected to the cut open end of the colon or large intestine allowing the stool to empty into a bag which is held on to the skin by gentle adhesive.

Types of Colostomy

A colostomy may be placed temporarily to allow an infection or other condition inside the abdomen to heal before normal continuity of the bowel is restored. In operations where the entire rectum must be removed (such as cancer) the colostomy may be permanent.

Colostomy Postoperative Care

An interstomal therapy nurse will commonly give patients extensive teaching on the management and care of the colostomy and the colostomy pouch. These nurses are generally available by phone for consultation during regular business hours.

Colitis

Ileal Pouch — Anal Anastomotic Procedure / Restorative Proctocolectomy / Ileoanal Pull Through Procedure / J-Pouch

Both chronic ulcerative colitis and familial adenomatous polyposis, many years ago when surgery was required, resulted in removal of the entire colon, rectum and anus and a permanent ileostomy. In 1971 Drs. Parks and Nichols developed an operation whereby the colon and rectum are removed, the anal sphincter muscles are spared, a new rectum is made out of the last part of the small intestine which is sewn in place where the old rectum used to be. This is usually accompanied by a temporary diverting ileostomy which is closed 8 weeks after the major operation.

While usually done through a long midline incision, in selected thin patients who have had few intraabdominal operations, this operation can be accomplished laparoscopically.

Preparing for Surgery

A full bowel prep is required prior to surgery including mechanical cleansing and antibiotic pills to decrease the levels of bacteria in the colon theoretically minimizing the risk of infection.

After Surgery

Hospitalization: If the operation can be accomplished laparoscopically hospitalization stay may be as short as 4-5 days if the patient does not develop and ileus (temporary intestinal paralysis, this occurs in approximately 50% of patients). If performed open a 7-10 day hospital stay may be expected. A specially trained nurse will give detailed instructions regarding care of the temporary ileostomy before discharge from the hospital. Criteria for discharge include being able to walk without assistance, pain controlled by pills instead of shots, tolerating a regular diet, and satisfactory instruction in care of the ileostomy.

Aftercare: Normally the patient will be seen in the office between one and two weeks after surgery. At six weeks post-op, arrangements are made for an outpatient Hypaque enema where water soluble contrast is put through the anus into the J-pouch through a small tube such as a Foley catheter. This is to assess for any leaking from the new rectum. If a small leak is detected the test will be repeated at monthly intervals until it is closed. Once there is no demonstrated leak then the patient may be scheduled for ileostomy closure.

Pouchitis

Approximately 50% of patients who have a J-pouch performed for ulcerative colitis and 10-15% of those who have it for familial polyposis will develop a condition called pouchitis. This is poorly understood inflammation of the J-pouch or new rectum which results in crampy pain, frequent small stools often with blood in them and low grade fever. The actual cause has been widely debated, but is unclear. It usually responds to oral antibiotics such as Flagyl and/or Cipro. Rarely a short course of steroids is needed to calm the inflammation.

Ileostomy

What is an Ileostomy?

An ileostomy is a connection between the cut end of the last part of the small intestine, the ileum and the intestinal skin.

What Types of Ileostomy are There?

An ileostomy may be temporary allowing the contents of the bowel to empty into a bag on the abdominal wall for a period of time to allow healing of the bowel downstream from surgery or infection. Rarely an ileostomy is permanent if the entire colon and rectum have had to be removed for some reason.

Ileostomy Postoperative Care

It is important that the ileostomy protrude above the skin level so the contents may fall from the spout straight into the ileostomy pouch which is gently adhesed to the surrounding skin of the abdomen. The contents of the small bowel are very alkaline which can be very irritating to the skin. Once the skin becomes too raw then it may be difficult or impossible to cause the appliance to stick and this results in obvious difficulties. Thus careful communication between the patient and the interstomal therapy nurse and/or physician is important. It is best to treat problems early rather than late so as to protect the surrounding skin appropriately.

Ileostomy Closure Surgery

Ileostomy closure is an approximately one hour operation through about an inch and a half to two inch incision made in the right lower quadrant around the stoma. The protruding bowel is amputated; the lower end which has been disconnected for weeks is brought up and reconnected to the proximal small intestine. The connection is then replaced into the abdomen, the muscle is closed, stitches are placed in the skin, but not tied and the wound is packed open. On postoperative day three pain medicine is given and the skin anesthetized. The sutures are then closed allowing the wound to heal with minimal risk of infection, but without requiring months of packing to the wound. These sutures are then removed approximately 7-10 days later in the office.

After Ileostomy Closure Surgery

Initially bowel movements tend to be loose and very frequent. Stool frequency of 12-20 times a day is not uncommon. A number of constipating agents are used either singly or in combination in order to slow the bowels down or thicken the stool enough for the sphincters to hold. At 6 months post ileostomy closure the vast majority of our patients have 6 or fewer bowel movements a day with good control and without the sense of urgency requiring them to be near a bathroom most of the time.

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