STOMA OSCE 1) Types of questions that can be asked during the PE an OSCE might go like this. You are brought to see a patient with the abdomen exposed and in the LIF there is a stoma bag. Introduce yourself, get permission to examine, ask are you in pain. Q.1 What is this? A.1This is a stoma bag which is most probably a colostomy. What is a stoma? it is a surgically created communication between a hollow viscus or epithelial surface and the skin or external environment. Q.2 What are the different types of stomas? A.2 Colostomy; Ileostomy ; Transverse loop colostomy; Can be mistaken for ileal conduit. Technically a tracheostomy is also a stoma. Q.3 What would make you decide which one this is?A.3 Position, flush with skin, contents ie. SITE, SPOUT,WHAT COMES OUT! Site: RIF=ileostomy, LIF=colostomy, midline loop, emergency colostomy. Spout: Colostomy doesn't need a spout and is larger than ileostomy (which needs a spout to protect against pancreatic enzyme secretions), larger than urostomy. Smaller if it is retracted or stenotic, larger if prolapsed, number of lumens: possibilities: end, loop, double barrelled What comes out: Green=ileal fluid, feces, urine, mucus, blood, serosanguineous fluid. Q.4 List complications related to these?
Early 1. Bleeding can occur, but within reason (eg 5-10 mL of blood in the stoma bag after the patient returns from theatre), this is a good complication because it shows there is a good blood supply, which means that the second early complication, Mucosal sloughing or necrosis due to ischaemia, is unlikely to occur. 2. If ischemia /necrosis occurs, it requires re-siting. This is evidenced by a dusky color to the stoma. This can be prevented by ensuring good vascular supply in theatre, by raising the blood pressure and measuring the vascular response to a test bleed. 3. Retraction can occur, this may result in a fecal peritonitis, which has a high mortality which is dependent on the time it takes to return to the operating theatre. The mortality rises linearly with time.
4. Edema or Obstruction can occur early, this is due to oedema or faecal impaction. Usually this is transient and may be due to a plugged opening, it may be treated by clearing the opening with a gloved finger and using NSAIDS. 5. Ileostomy can leak causing skin irritation, this is mainly due to the pancreatic excretions 5. High output ileostomy dysfunction can occur with high volume loss and electrolyte depletion. Common causes of high output loss include. 1. Inflammatory bowel disease 2. Para-intestinal sepsis 3. Subacute obstruction The treatment for this is to establish two intravenous lines, replacing the maintenance requirements (3 liters over 24 hours with 100 mmol NA and 60 mmol K in one and the deficit/predicted ongoing loss (estimated three hourly)in the other. The normal expected output for an ileostomy is 4-500 mL, an excessive output is more than 1 liter per day. If this does not settle, somatostatin analogues such as octreotide may be used.
Late 6. Prolapse of bowel, if recurrent requires re-siting. 7. Parastomal hernia, which may result in risk of obstruction or strangulation, re-siting may be necessary. 8. Retraction of spout 9. Stenosis of the stomal orifice 10. stoma diarrhea, underlying disease, inappropriate diet 11. vit B 12 deficiency, megaloblastic anemia, anemia of chronic disease. 12. kidney stones, gallstones: loss of ileum, loss of resorption of bile salts, water loss. 13. short gut syndrome: fluid/electrolyte loss 14. underlying disease: Crohn's: peristomal fistulae, proximal obstruction 15. psychological and psychosexual problems. Q.5 Name one physical finding that may give you an indication as to whether this is permanent or temporary intervention? A.5 Check if patient has a patent anus or not. Some common reasons for abdominoperineal resection include: low rectal ca, familial polyposis coli, severe ulcerative colitis. (Crohn's is not) Q.6 Can the descending colon be used for a stoma? No. it is retroperitoneal, only the transverse or sigmoid can be used for a stoma.
Q.7 If the patient is losing a lot of fluid through the stoma what kind of I.V. solution would you use? Hartmann's because it resembles plasma. Q.8 Where would you choose to place the stoma? A. Away from the umbilicus, Away from bony prominences (costal margin, ASIS), away from skin creases, away from existing scars/wound sites, through the rectus sheath to prevent herniation, at a site accessible to the patient's dominant hand, where the patient can see the bag. Assess the patient lying and standing, with clothes on. Q.9 You are brought to see a patient who has black marks and lines on the belly. If asked what these are, consider the possibilities of marks on the belly: tattoos, surgical tattoos from wounds, hematoma from injections of heparin, insulin lipohypertrophy, pigmentation, a visit by the stoma nurse to site a stoma. Q10. What are the indications for a stoma? Feeding, decompression, lavage, diversion, exteriorization. Q11. What are the normal output rates for stomas? Distal colostomy should produce solid faeces Ileostomy will produce 500-700 ml/day of liquid effluent Q 12. What would you consider if output is in excess? If excess output consider: 1. Inflammatory bowel disease 2. Para-intestinal sepsis 3. Subacute obstruction Q13. If Reduced action, then Consider simple constipation or obstruction Q 14. Why is the general condition of the patient important? To assess hydration, nutritional status, and possible reason for stoma. Q 15. What practical problems would you anticipate with a stoma and what postoperative advice would you give the patient? This stoma drains the contents of you
What is a Loop Stoma or Loop Ostomy? A loop stoma is a stoma where both the upstream (proximal) and downstream (distal) openings of the bowel are brought out through the same place in the abdominal wall (see photo A). The proximal opening of the stoma drains stool from the intestine, while the distal opening of the stoma (the mucous fistula) drains mucus from the part of the bowel that leads to the anus (or internal pouch).
Photo A – Loop Stoma Loop stomas are typically constructed for either ileostomy or colostomy stomas, and the size and shape can vary from person to person. Occasionally, a loop stoma can look just like an end stoma (see photo D). Sometimes, the distal opening of a loop stoma is very obvious, but it in some cases it is attached close to the skin, making it difficult to see. For some people, the mucus that comes out of the opening of the distal stoma can make it difficult to achieve and maintain a good pouching system seal. Compared to a loop stoma, a double-barrel stoma is where two distinct stomas are made and brought through the abdominal wall. The stomas may or may not be separated by an expanse of skin (see photos B and C). As with loop stomas, one stoma is usually called the proximal stoma, while the other is called the distal stoma.
Another type of stoma is called an end stoma. Compared with a loop stoma and a double-barrel stoma, an end stoma has only one opening (i.e., one stoma – see photo D).
It's important to talk with your surgeon to ensure you understand exactly which type of surgery you have had. ^ top Loop Stoma Bridge Depending on the surgeon and the type of surgery, there may be a support device used to hold the loop stoma in place while it heals. This is commonly referred to as a rod or bridge. This support device is temporary and can stay in place anywhere from 4 to 10 days, depending on the surgeon's preferences and the healing process. It's generally removed before going home and can be made of glass, rubber, or plastic (see photo E).
^ top Closing the Loop
Generally, loop stomas are temporary. How long they remain in place depends on the person and the reason he or she had surgery. Closing a loop stoma involves taking both ends of the stoma and re-attaching them with sutures after the stoma has been taken down (i.e., removed from the opening through which the stoma exited). This results in a scar at the site of the stoma. Depending on the surgeon's preference, the stomal site may be closed with sutures. In some instances, the wound is left open with a dressing in place and is allowed to heal this way. Closing a loop stoma is not as technically difficult as stoma construction surgery. It's important to note, however, that the surgeon will still need to cut through your abdominal wall. Therefore, after surgery, you will need to be careful before going back to regular activities or lifting heavy objects in order to allow the surgical area to heal completely. Occasionally, it's necessary to reopen the original abdominal wound. Your surgeon will tell you if this will be necessary. You also can find more information on this topic in the Reversal section of this site.
^ top Recovery from Stoma Reversal Recovery from stoma reversal is usually faster than recovery from the original surgery to create the loop stoma. Occasionally, there is localized swelling (edema) in the intestine where the loop was closed. This may narrow the path for food and liquids to get through and cause nausea, vomiting, and/or cramping. These symptoms usually pass with gut rest (e.g., not eating or drinking anything for a short period of time, and having an intravenous drip in place to stay hydrated). The reason for your stoma formation can affect how quickly you recover after surgery. For instance, if your surgery was for a loop colostomy to allow healing of the intestine further down, it should not take too long to get back to a normal routine. If the surgery was for an internal pouch formation, such as a J-pouch, it may take longer while the pouch becomes used to its new function.
