Ileostomy
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Assistant Editor-in-Chief: Soumya Sachdeva
Overview
An ileostomy is a stoma that has been constructed by bringing the end of the small intestine (the ileum) out onto the surface of the skin. Intestinal waste passes out of the ileostomy and is collected in an external pouching system stuck to the skin. Ileostomies are usually sited above the groin on the right hand side of the abdomen.
Indications
Ileostomy is necessary when disease or injury has rendered the lerge bowel incapable of safely processing the intestinal waste typically because the colon has been partially or totally removed.
Reasons for Having an Ileostomy
Ileostomies are necessary where disease or injury has rendered the large intestine incapable of safely processing intestinal waste, typically because the colon has been partially or wholly removed. Diseases of the large intestine which may require surgical removal include:
- Crohn's disease
- Ulcerative colitis
- Familial adenomatous polyposis
- Total colonic Hirschprung's disease
An ileostomy that may also be necessary in the treatment of colorectal cancer; one example is a situation where the tumor is causing a blockage. In such a case the ileostomy may be temporary, as the common surgical procedure for colorectal cancer is to reconnect the remaining sections of colon or rectum following removal of the tumor provided that enough of the rectum remains intact to preserve sphincter function. In a temporary ileostomy, a loop of the small intestine is brought through the skin, and the colon and rectum are not removed. Temporary ileostomies are also often made as the first stage in surgical construction of an ileo-anal pouch, so fecal material doesn't enter the newly-made pouch until it heals and has been tested for leaks – usually a period of eight to ten weeks. The temporary ostomy is then "taken down" or reversed by surgically repairing the loop of intestine which made the temporary stoma and closing the skin incision.
Types
- Permanent ileostomy or end ileostomy
- Temporary ileostomy
- End ileostomy
- Loop ileostomy
Individual Indications
- Permanent end ilostomy - It is performed in conjunction with a total proctocolectomy in inflammatory bowel diseases like Crohn's disease , ulcerative collitis or polyposis coli
- Temporary loop ileostomy - It is performed when temporary diversion of ileal contents is required.It is commonly performed to divert the ileal contents temporarily to protect a tenuous ileorectal or ileoanal anastomosis following total coloctomy or proctocoloctomy, e.g.,adenomatous polyposis. Its advantage is to allow healing of the distal anastomosis well and,thus, allow safe passage of faeces through the anal orifice in future after closure or ileostomy.
- Temporary end ileostomy with mucus fistula - Occasionally a temporary end ileostomy of the proximal end of the ileum are constructed, after resection of a gangrenous segment of bowel or a perforated caecal lesion, when primary anastomosis is contraindicated.
Methods
- Site of election; Both the types are usually sited on the right iliac fossa, near the outer margin of the right rectus muscle about 5 cm. lateral to the midline and 4 cm. below the umbilicus.
- The ileal stoma should protrude as a nipple for at least 3-5 cm above the skin surface.This facilitates the fluid effluent to pass directly into the collecting bag and the peristomal skin. It prevents peristomal skin irritation and break down.
- The edge of the ileal mesentery should be sutured to the peritoneum of the lateral abdominal wall.This prevents herniation of small bowel loops through the peraileal stromal space.
- A stroma adhesive disc is applied to the ileostomy stoma in the operation theatre.An ileostomy bag or pouch is placed over the disc.People with ileostomies either use a 'closed end' pouch which must be thrown away when full, or a 'drainable pouch' that is secured at the lower end with a leak proof clip.
- Ostomy pouches fit close to the body surface and are usually not visible under the regular clothing unless the patient allows the pouch to become full.
- The ileostomy starts to work within 48 hours.
- It produces a daily output of 500 to 700 ml liquid or semi-liquid contents.
- Ordinarily the pouch must be emptied several times a day and changed every 2-5 days.
Complications of Ileostomy
Early complications:
- Occasional necrosis of the distal ileum due to devascularisation.
- Parastomal infecction
Late complications:
- Fistulaa
- Prolapse
- Stricture
- Parastomal skin ulceration
- Obstruction of ileostomy with food fibres e.g, potato skin, raw vegetables.
- Effluent amount larger than 1000ml/day can cause fluid and electrolyte imbalance. This requires urgent ayyention and treatment: correction of fluid and electrolyte imbalance,use of drugs like loperamide or lomotil, use of bulk laxatives like isopgul husk.
- Kidney stones
- Gall stones.
Living with an Ileostomy
People with ileostomies must use an ostomy pouch to collect intestinal waste. People with ileostomies typically use an open-end, or "drainable" pouch that is secured at the lower end with a leakproof clip, rather than a closed-end pouch which must be thrown away when full. Ordinarily the pouch must be emptied several times a day (many ostomates find it convenient to do this whenever they make a trip to the bathroom to urinate) and changed every 2-5 days, when the wafer starts to deteriorate. Ostomy pouches fit close to the body and are usually not visible under regular clothing unless the wearer allows the pouch to become too full.
Some people find they must make adjustments to their diet after having an ileostomy. Tough or high-fiber foods (including, for example, potato skins and raw vegetables) are hard to digest in the small intestine and may cause blockages or discomfort when passing through the stoma. Chewing food thoroughly can help to minimize such problems. Some people also find that certain foods cause annoying gas or diarrhoea. Nevertheless, people who have an ileostomy as treatment for inflammatory bowel disease typically find they can enjoy a more "normal" diet than they could before surgery.
Other complications can include kidney stones and gallstones.
Other Options
Since the late 1970's an increasingly popular alternative to an ileostomy has been the ileo-anal pouch. With such a pouch an internal reservoir is formed using the ileum and connecting it to the anus, after removal of the colon and rectum, thus avoiding the need for an external appliance