Crash course in stomas
Thank you to the Paediatric Stoma Care Guidebook 2019, written by The members of the Global Paediatric Stoma Nurses Advisory Board (GPSNAB).
You are working in A&E, and a child comes in with a ‘funny-looking stoma’. The parents have been told to come to ED because it’s the weekend, and no specialty teams are available. Where do you start?
Children, babies and even premature neonates can have a stoma. A stoma is a surgically formed ‘mouth’ or opening into a hollow organ.
Do you know the difference between stomas?
Faecal Stoma
- End ileostomy/colostomy
- Loop ileostomy/colostomy
- Stoma with mucous fistula
Urinary Stoma/ Diversions
- Vesicostomy
- Ileal conduit
- Ureterostomies
Continence Stomas
- Mitrofanoff/Monti
- Antegrade continence enema (MACE/ACE)
Feeding Stomas
- A gastrostomy or jejunostomy is a type of stoma. They often have the same problems as other stomas, even though we often think of them differently. They are covered in more detail here.
Why do Children/Young Adults need Stomas?
The majority of the stomas made in neonates and children are reversed. The length of time with the stoma varies from a few months to a few years, depending on the diagnosis, the situation, and the family and medical team’s preferences.
Indications for faecal stoma
Neonates
- Anorectal malformation/ cloacal malformation: A stoma (colostomy) is often formed to allow them to poo until the baby has the operation to create a new bottom.
- Hirschsprung’s disease: Most babies with Hirschsprung’s disease will be managed without a stoma, but if the washouts don’t work a stoma (ileostomy) can be formed. A stoma can also be formed as part of the operation to determine how much bowel is affected (a levelling stoma).
- Necrotising enterocolitis (NEC): If a baby needs an operation for NEC, they often need part of their intestine removed. Joining the ends may not be safe straight away. They will then have a stoma (ileostomy/ jejunostomy).
- Other causes of bowel injury in babies: Faecal stomas are also formed if a baby has a bowel blockage, bowel damage or perforation for another reason and the bowel cannot be safely joined back together at the first operation. Other reasons include: small bowel atresia, malrotation and volvulus, meconium ileus.
Children / Young Adults
- Constipation: Occasionally, constipation is so bad that children need a continence stoma or a faecal stoma. This can still be reversed in the future if it is not needed any more.
- Inflammatory bowel disease: when medical management doesn’t work or in an emergency situation, a stoma can be formed to divert the poo and rest the bowel.
- Accidents: Occasionally, in trauma, a stoma can be formed as part of a damage-control laparotomy in a very sick child or when there is extensive damage to either the bowel, the pelvis or the bottom. The stoma allows control of contamination (phase 1 DCS) before full resuscitation (and further investigations/operations).
Indications for urinary stomas
- Posterior urethral valves: If a baby is born with posterior urethral valves is too small for cystoscopy and catheters aren’t an option a vesicostomy can be formed.
- Neuropathic bladder: If a baby has a neuropathic bladder and catheterisation is not an option, a vesicostomy allows the bladder to drain without creating high pressure that can damage the kidneys
- Trauma: Supra-pubic catheters are typically used to divert the urinary stream in trauma but other forms of urinary stomas are an option if a suprapubic catheter is not.
Continence stomas:
The appendix or a small piece of intestine can be used to make a tube that connects the bladder (Mitrofanoff / Monti-mitrofanoff) or bowel (ACE – antegrade continence enema) to the abdominal wall. This forms a continent stoma (one that doesn’t leak) and allows a tube to be passed to drain urine or to give an enema. This allows children who would otherwise be incontinent to be clean e.g. with severe constipation or a neuropathic bladder.
A beginners guide to stoma spotting
The aim is to work out what type of stoma this is (it is often written in the notes or the parents/carers know but that’s not the point!). Helpful questions are: what is coming out of the stoma, how many holes does it have, does the end stick out and is it a happy stoma?
What is coming out?
How many holes does it have?
Does the end stick out?
Is it a happy stoma?
What could have gone wrong?
Stoma complications either happen early after a stoma is formed or later.
- Early – Necrosis, wound breakdown, infection,
- Later – Prolapse, retraction, stricture, bleeding, granulation tissue, leakage around the bag/ bag not sticking.
What are the risks?
- Skin irritation Although the stoma itself has no sensation, the skin surrounding it does and it can become irritated by both the adhesive of the stoma bag, and also by the stool itself. Often, these irritations can be minor, but in some cases they can start to cause the skin to break down. The nursing staff and the stoma nurse specialists will observe for early signs of irritation.
- Prolapse A prolapse is when the bowel becomes longer and protrudes through the opening of the stoma. Although this can be very frightening for parents, it is not usually serious. As long as the bowel remains pink and active, we will simply keep a close eye on it.
- Retraction Retraction (also known as inversion or ‘moating’) of the stoma is when the stoma sinks below skin level. This can lead to problems with applying the bag. The nursing staff and stoma nurse specialists will have suggestions on how to help.
- Bleeding The stoma will occasionally bleed, especially when touched. This is normal unless the bleeding does not stop.
Troubleshooting
Not happy taking a stoma bag off
It can be intimidating removing a stoma bag especially if you’re not happy putting it back. The parents will often be expert at this even if they are reluctant to take the bag off because it is sore for the child. It is worth having someone else come with you and having a camera to take a picture of the stoma (this can be the parent’s phone) so that the bag is only taken off once. Here’s a happy stoma bag change…
Leaking stoma bag
This can be really tricky to manage and stoma nurses are essential. Some basic tricks are:
Make sure that the stoma bag is warm before you put it on – warm it up under your arm or in your pocket. This makes it more flexible and sticky and the seal will be better.
Prepare, take your time and have enough help. If the child is wriggling, changing a stoma bag is really hard so get all the kit together beforehand including plenty of cleaning supplies. Cut the new bag before you remove the old one and use stoma bag removing spray. Remember to dry the skin completely.
There are many products that are designed to help with different bags, fillers to even the skin around the stoma, powders to help the seal.
Make friends with your stoma nurse. If they have written a plan follow it if at all possible.
Skin breakdown
When a bag leaks, is changed frequently or is cut poorly the skin around the stoma breaks down. Barrier wipes / sprays and stoma removal sprays are a good start but it takes time and expert help to heal.
Rectal discharge
It is normal to have some rectal discharge after stoma formation. It can be due to leftover stool in the rectum, spill over from a loop stoma, ongoing mucous production from the bowel or diversion colitis. If the discharge is foul smelling or bloody the medical team looking after the child should be made aware and can often help with diversion colitis.
High output faecal stoma
Stomas can have a high output if they are made close to the stomach or if the child is sick for any reason (like a form of diarrhoea). It is important that they don’t get dehydrated, stoma losses >20ml/kg typically need replacing intravenously.
Prolapse
Some stomas prolapse all the time (chronic) and some prolapse acutely. If the stoma is pink and healthy and working (passing gas and stool/urine depending on the type of stoma) that is reassuring. If it is not, then the child should be transferred urgently to a surgical centre. If the stoma is acutely prolapsed then it should be reduced. Put lignocaine gel / lots of sugar on the stoma to draw the swelling out, leave it alone for around 40 minutes and then try and push the stoma back5. Sometimes the stoma will need an operation to revise it. If this is a chronic problem then revision is usually an elective procedure.
Poor growth
If the colon is bypassed by a stoma the body often doesn’t take up enough salt and this can slow growth. The serum sodium will be okay but in the urine they will be low. It is worth checking a urinary sodium and supplementing with oral sodium if the levels are below 20mmol/l.
Selected references
1. Farrugia MK, Malone PS (2010) Educational article: The Mitrofanoff procedure. J Pediatr Urol 6:330–337. https://doi.org/10.1016/j.jpurol.2010.01.015
2. Fracs SKK, Krois W, Lacher M, et al (2020) Optimal management of the newborn with an anorectal malformation and evaluation of their continence. Semin Pediatr Surg 150996. https://doi.org/10.1016/j.sempedsurg.2020.150996
3. Hutton KAR (2004) Management of posterior urethral valves. Curr Paediatr 14:568–575. https://doi.org/10.1016/j.cupe.2004.07.013
4. Okada T, Honda S, Miyagi H, Taketomi A (2011) Technical Points Regarding New Enterostomy Formation for Incarcerated Stomal Prolapse in Loop Enterostomy. Surg Sci 02:488–792. https://doi.org/10.4236/ss.2011.210107
5. Landim Júnior JA, Moura Júnior JV, Lima Forte HB, et al (2020) Topical osmotic therapy for a prolapsed incarcerated ostomy. J Pediatr Surg Case Reports 57:101454. https://doi.org/10.1016/j.epsc.2020.101454
6. Forest-lalande L, Vercleyen S, Fellows J (2018) Paediatric stoma care: Global best practice guidelines for neonates, children and teenagers. 3–70
7. Holcomb III GW, Murphy JP, Ostlie DJ (2014) Ashcraft’s Pediatric Surgery, 6th ed. Elsevier Saunders
