Issue 147 Ileostomy/colostomy management: the four fs in stoma care

CLINICAL

ILEOSTOMY/COLOSTOMY MANAGEMENT: THE FOUR Fs IN STOMA CARE This article focuses on the key aspects of care for patients with stomas.

Rebecca Gasche Specialist dietitian, Countess of Chester Hospital NHS Trust Rebecca has a keen interest and specialises in gastroenterology dietetics. She currently works in the community setting in the Chester area, running clinics and group sessions to manage a wide range of gastroenterology conditions.

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A stoma, with the literal meaning of ‘mouth’ in Greek, is an opening which (in this context) connects the small or large intestine to the outside of the body, so waste products may be removed and emptied into an external bag attached to the skin.1 Approximately 13,500 people in UK undergo surgery for a stoma every year2 and its management may have an immense impact on physical and mental health.

FORMATION

Here are a number of reasons why a patient requires a stoma, often linked to diseases such as:1 • inflammatory bowel disease (Crohn’s, ulcerative colitis) • bowel cancer • diverticulitis • bowel obstruction • ischaemic bowel • abdominal trauma • anal stenosis • faecal incontinence The surgery will either remove the diseased part of the bowel, or provide a period of rest for a section of the bowel to recover from inflammation.

Therefore, stoma formation may be

permanent or temporary.

The two most common stomas are a colostomy (where the colon is connected to the skin opening) and an ileostomy (the ileum, the last part of the small intestine, is connected to the skin opening). Table 1 below outlines the different colostomy and ileostomy that may be formed.

FLUID

Dehydration is common, in particular in patients with ileostomies who have had large amounts of their ileum removed, and can often result in a readmission to hospital and acute renal failure.4 Post-operatively, the most common losses seen in ileostomy patients are fluids and sodium. This is particularly seen in patients who have had a total colectomy, as this means that the entire colon has been removed, where most of the fluid and sodium is normally absorbed. Within the first six to eight weeks especially, patients may lose 12002000ml fluid and 120-200mmol sodium/ day. After eight weeks, the ileum then adapts to absorb, and fluid losses usually reduce to 400-600ml/day.1 Due to the loss of sodium, patients are also encouraged to add salt to their diet.

Table 1: Colostomy and ileostomy procedures1 Loop colostomy End colostomy known as a Hartmann’s procedure Double barrel colostomy Temporary or loop ileostomy End ileostomy Continent ileostomy

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The colon is sutured to the abdomen and there are two openings: one for intestinal waste and one for mucus produced by the GI tract.

The sigmoid colon and upper rectum is removed; an end colostomy is formed.

Both ends of the colon are brought out onto the abdomen.

A loop of the small intestine is brought to the skin and the colon and rectum remain in situ. This is usually reversed 8-10 weeks later.

The colon and rectum are removed and the end of the small intestine is brought through the skin.

An internal pouch is created and the stoma is connected to a valve implanted in the skin, which can be emptied using a catheter.

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CLINICAL Table 2: The differences in surgeries that are performed to create the stoma3 Right hemi-colectomy Left hemi-colectomy Abdominoperineal resection Anterior resection Sigmoid colectomy Hartmann’s procedure Total colectomy Pan-proctocolectomy

Right half of the colon is removed.

Left half of the colon is removed.

Rectum and anus removed; colostomy formed.

Removal of cancer in the rectum.

Sigmoid colon removed; two ends joined together.

Sigmoid colon and upper rectum removed; end colostomy formed.

Entire colon removed; permanent ileostomy or small bowel will be joined to rectum.

Colon, rectum and anus removed; permanent ileostomy formed.

Contrary to normal physiological function, patients with ileostomies are discouraged from drinking additional fluids to improve hydration.

This comes as a result of the hypotonic nature of normal fluids (such as water, tea and cordials) and the leaky nature of the upper small intestine, meaning that patients can lose more fluid from their stomas than they consume. Patients with high output stomas, producing >1500ml/ day,5 are advised to limit hypotonic fluids to 1000ml/day and take an additional 1000ml from a rehydration solution, such as St Marks Solution or Dioralyte (made to double strength).

These rehydration solutions help to prevent dehydration by replacing electrolytes.

St Marks Solution can be made at home with the following ingredients: 1 level 5ml teaspoon salt 6 heaped 5ml teaspoons of glucose ½ heaped 2.5 teaspoon of sodium bicarbonate Mixed in 1L water Fluids are also discouraged from being taken with meals, ideally avoiding 30 minutes before and after eating, to minimise dehydration as a result of the gastric fluid production increasing fluid losses.6 Types of fluids should also be considered, as fizzy drinks can cause excess gas in stoma bags and, therefore, some patients choose to limit or avoid these.

FIBRE

Dietary fibre can be described as a component of food, which includes ‘all carbohydrates that are neither digested nor absorbed in the small intestine and have a degree of polymerisation of three or more monomeric units, plus lignin.’7 In simpler terms, it is also known as the ‘roughage’ in our diet. It helps to regulate our bowel

movements and diets high in fibre have been linked to reducing the risk of diabetes and bowel cancer, as well as helping to lower cholesterol.

It is usually advised that patients follow a low-residue (low-fibre) diet in the first six to eight weeks following both colostomy and ileostomy formation, but regarding diet following this period, there are few clinical trials to support any one in particular.1 Further advice tends to focus on adjusting foods depending on stoma function, for example, avoiding certain foods which are poorly digested and may cause a potential blockage (stoma obstructives), choosing lower fibre options if an increased output is noticed, or avoiding foods which cause more gas or odour.

Patients should be encouraged to aim to return to a healthy balanced diet following eight weeks post-op if a normal output volume/consistency has been achieved. It is important to remember that fibre tolerance will be individual and dependant on the extent of surgery and normal GI function. Some patients may easily return to a diet high in wholegrains, beans and pulses, whereas others may have to reintroduce these foods at a slower rate, or limit some altogether. Healthcare professionals need to be able to support patients with this and encourage the reintroduction of fibre once it is appropriate to do so.

For patients who have had surgery for cancer, constipation may occur due to medication use, reduced activity, or poor diet and fluid intake.

Ensuring that patients who are suffering with constipation have adequate dietary fibre (beware of stoma obstructives) and fluids, can help to improve GI function.8 For patients with a high or loose output, a low-fibre diet has been shown to improve output www.NHDmag.com August/September 2019 - Issue 147

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CLINICAL Table 3: Food examples High-fibre foods Wholemeal bread, whole fruits, brown pasta, rice, whole vegetables, nuts, seeds, wholegrain cereals (Shredded Wheat, Bran Flakes) Stoma obstructives Apple peel, sweetcorn, chinese vegetables, dried fruit, nuts, mushrooms

consistency and volume and should, therefore, be advised.9 FOLLOW-UP

Stoma formation is a major surgery and comes with a great deal of aftercare and certain skills are required, therefore, it is vital that patients have the correct support and follow-up postoperatively. Stoma nurses play a crucial role in teaching skills such as stoma care and changing stoma bags; research has shown that the early promotion of stoma-management skills improves the psychological adjustment that is required following a stoma formation.10 Further studies also suggest that this should be continued upon hospital discharge, as the need to acquire all practical skills for stoma care within the short period of hospitalisation may lead to psychological distress among patients, as well as experiences of anxiety, fear and insecurity.11,12 As a result, preparation for discharge is considered a stressful event for many patients and psychological support should be provided alongside post-operative education.13 Despite these suggestions, experiential evidence has shown that this does not always occur, due to staff shortages and increased workloads.14 There have been a number of studies looking further into the psychological effect that stoma surgery can have on a patient, concluding that it can often lead to a series of physical and psychological stresses, as well as maladjustment and poorer health outcomes.15-17 Common impacts include altered body image, the loss of body function, decreased self-esteem and perceived self-care difficulties. Patients with a stoma also have significantly higher levels of depression than those without.18 The type of surgery should also be considered when offering psychological support, as several clinical studies have reported that patients who have emergency stoma surgery may have greater 38

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Low-fibre foods White bread, peeled fruits without pips/piths, eg, pears, peaches, banana, melon, white pasta, rice, peeled vegetables - cooked well and mashed, smooth nut butters, white cereals (Cornflakes, Rice Krispies, Cocoa Pops) Gas producing Beans/pulses, cabbage, broccoli, cauliflower, alcohol, onions

difficulty adjusting to the sudden body image change and functional loss, due to the fact that patients have little time to anticipate or accept their future living with a stoma.13,19 Therefore, patients admitted for emergency surgery are at a higher risk of suffering from stress and psychological distress, which can affect future coping and recovery,19 whereas patients admitted for elective stoma surgery may anticipate the loss and grief process after the surgery.19 These findings emphasise the importance of nurse assessment of a patients’ mental health and the need to provide relevant psychosocial care for a patient following stoma surgery.

Follow-up is also required to ensure that patients are not nutritionally compromised following surgery. As well as managing stoma output and hydration, some vitamin/mineral replacements may need to be considered.

Following a total colectomy, the absorption of other nutrients should be unaffected and the absorptive capacity of the small intestine remains intact. A small number (3-9%) of patients have been estimated to suffer from vitamin B12 deficiency and some patients may find absorption of bile acids are also affected.

This is thought to be due to reduced absorptive capacity due to ileal involvement, inadequate dietary intake or bacterial overgrowth. As the ileum contains B12 receptors and bile salt transporters, those patients who have had ileal resection often suffer from B12 deficiency and fat malabsorption. Fat malabsorption may lead to steatorrhea and deficiencies in fat soluble vitamins A, D, E and K.20-22 CONCLUSION

Dietitians can play a key role in supporting stoma patients to achieve a healthy balanced diet, avoid nutritional deficiencies, achieve optimal consistency and prevent dehydration.