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Am Fam Physician. 2004;69(1):193-195

An unknown but certainly significant number of patients have colostomies following surgery for cancer, ulcerative colitis, Crohn's disease, diverticulitis, and other serious bowel conditions. Patients with colostomy are at increased risk of depression and social isolation as well as physical problems related to their stoma or the condition for which it was formed. A review by Fowler and colleagues emphasizes the need for multidimensional care of these patients.

Patients are almost always concerned about leakage and odor from colostomies. Ostomy systems vary in design, but those for the sigmoid or descending colon must handle solid intermittent output and require a closed bag that can be changed one to three times daily. Conversely, ileostomies and colostomies that drain the proximal colon receive frequent liquid or semi-solid outputs and require a bag that can be drained and resealed several times per day. Filters can be incorporated to prevent distension of the bag with gas. Drops, powders, and sprays are used to absorb odors. Leakage, commonly caused by skin irregularities around the stoma, may require fillers of paste or wafers to provide a smooth surface for attachment.

Skin problems around the stoma are common. Bleeding usually is attributable to excessive cleaning. Skin irritation and maceration often indicate leakage. If the affected area of skin is close to the stoma, the flange opening may be too large. This situation commonly occurs when postoperative shrinkage (up to 30 percent) creates a mismatch between the stoma and the appliance, allowing bowel products to be in prolonged contact with skin. Although allergic reaction to ostomy materials is rare, physical or chemical irritation may occur, especially if the appliance is changed too frequently.

Mechanical problems with colostomies include herniation, prolapse, and stenosis. Approximately one third of patients who have colostomies for 10 years develop parastomal hernia, but only 10 percent of these require surgical intervention. Hernia may be embarrassing for the patient, thus exacerbating fears about the colostomy being visible. Herniation also can cause difficulties in adherence of appliances, resulting in leakage and skin problems. Abdominal support garments may help.

Bowel prolapse through the stoma is most common in patients with transverse-loop colostomies. If not engorged, prolapses can reduce spontaneously or be rolled back using a cold pack. Surgical repair is required if there is danger of bowel ischemia. Stenosis of the stoma causes pain and cramping and may be treated with manual dilatation, stool softeners, or surgery. Patients with colostomy also report phantom pain or rectal fullness, particularly after abdominoperineal resection, and these sensations often do not respond well to analgesics.

Realization: characterized by avoidance or denial of the loss followed by experiences of unreality or blunting
Alarm: characterized by anxiety, restlessness, fear, and insecurity
Searching: characterized by acute episodic feelings of anxiety and panic, and preoccupation with loss
Grief: characterized by feelings of internal loss and mutilation
Resolution: characterized by efforts to construct a new social identity

Although patients frequently are concerned about their diets following colostomy, the general advice is to eat a varied, well-balanced diet, but to exercise moderation with foods that cause gas (e.g., beans, onions, leeks, excessive fiber). High-fiber foods such as dried fruit, nuts, or popcorn can cause bolus obstruction, but a moderate amount of fiber taken with an appropriate amount of water is advised to avoid constipation. Diarrhea is more common in patients with ileostomies and proximal colostomies, and patients may not appreciate that fluid outputs are normal in these cases because of the loss of water absorption from the colon. Adequate fluid replacement is necessary in these patients.

More than 40 percent of patients with colostomy report sexual problems such as dyspareunia or erectile dysfunction. Psychologic and physical factors may contribute to sexual problems. These problems may be part of more global issues concerning body image and social acceptability. Support groups and organizations, as well as nurse specialists, can help patients with practical issues such as self-esteem and social isolation. A model of adjustment to significant change in body image has been developed (see accompanying table), but adjustment to colostomy varies significantly, often taking a year or longer.At least 25 percent of patients develop clinically significant depression following colostomy. Those who initially believed that the colostomy would be temporary have the worst prognosis for adjustment.

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