Ostomy care in a palliative care setting

Ostomy surgery can be curative or palliative, says Cynthia Worley, BSN, RN, CWOCN, and it’s important to determine what the goal of the treatment is for both the clinician and the patient.

Common reasons for ostomy surgery include inflammatory bowel disease, but more often cancer, Worley said at the Supportive Oncology Conference in Chicago. Patients may be obstructed, sometimes due to the chemotherapy, or have tumor growth, adhesions after surgery, or sometimes perforation.

“In bladder cancer patients, you have to do surgery because of hemorrhagic cystitis— it tends to be so painful that you have to remove the bladder because otherwise you’re constantly transfusing them,” says Worley, of the University of Texas, MD Anderson Cancer Center. “The other reason we see a patient with an ostomy is fistula development either from a tumor or some other process—radiation damage is one of the more common sources.”

There are several types of ostomies, including: ileostomy, colostomy and urinary diversion. Ileostomy is the standard care for patients with colorectal cancer—they have chemo and radiation first and then their surgical resection with a temporary ileostomy. “Temporary used to mean six to eight weeks but more and more we’re seeing patients who need additional chemotherapy after surgery and they may require chemo for up to nine months,” Worley said.

The normal ileostomy should be budded, it’s usually in the right lower quadrant, usually has intact peristomal skin, and the drainage from the ileostomy will be a thick, viscous liquid, with the consistency of oatmeal or pudding, Worley said.

For patients with colostomy the rationale for surgery is usually perforation or for carcinoma in general. Sometimes people with a temporary ileostomy come back for a complete colostomy. The appearance is supposed to be red and it’s an end or loop construction. The drainage is thick-to-formed stool, Worley said.

The third type is an ileal conduit or urinary diversion. The rationale for surgery comes from bladder, prostate, or metastatic rectal carcinoma or hemorrhagic cystitis. This type of diversion is often confused with an ileostomy, Worley says, because they look exactly the same and are both made of the small intestine. The drainage is the difference, she said, and it’s important to ask whether the color is yellow or green and whether it smells like stool or urine. She explained some of the common complications and their treatments:

Prolapse:Usually caused by increased abdominal pressure. Can be a result of exertion after surgery such as moving heavy objects. They usually don’t require surgery unless the blood supply is compromised.

Hernia:Probably the most common complication. It can happen with any ostomy. Caused by increased intra-abdominal pressure and weakened abdominal wall. Surgery is necessary only if it interferes with the function of the ostomy.

Retraction:This happens when patients have gained weight or there continues to be tension on the mesentery. The stoma may become recessed below the level of the abdominal wall. Usually no surgery unless the viability of the stoma is compromised.

Constipation: Only for colostomy patients; causes are poor fluid or fiber intake, narcotics, and dehydration. Treatments are stool softeners, fluids and manual irrigation.

Diarrhea: Causes with colostomy patients include medication, radiation, and high volumes of fiber. Treatments include increasing fiber intake and tincture of opium if severe.With ileostomy patients, not eating or drinking enough can cause diarrhea and so can blockages and high volumes of fiber. Treatments include a medicinal fiber regimen (off label), diphenoxylate and atropine, loperamide, and tincture of opium if severe.