Colostomy (and closure)

Posted in Disease Information

Introduction

A colostomy is a common surgical procedure that pulls a section of the large intestine (colon) through an opening in the abdominal wall.

The opening is known as a stoma. A pouch is placed over the stoma to collect waste products that would usually pass through the colon and out of the body through the rectum and anus (your back passage).

A colostomy can be permanent or temporary.

When is a colostomy needed?

A colostomy is needed when there is a problem with an area of the colon. For example, if the colon has become damaged, blocked or affected by conditions such as bowel cancer.

Types of colostomy

There are two main types of colostomies. They are:

• A loop colostomy, where a loop of colon is brought to the abdominal skin surface and two openings are made in the stoma
• An end colostomy, where one end of the colon is brought to the abdominal skin surface (stoma has one opening)

Loop colostomies are usually temporary. Temporary colostomies are sometimes used after surgery, injury or infection when a section of the colon has been damaged. This gives it time to heal before it is rejoined and the stoma is closed.

End colostomies are usually permanent but can be temporary. A permanent colostomy may be needed if the colon is severely damaged or if it is necessary to remove the rectum or anus.

An alternative to a colostomy is an ileostomy. This stoma is made from the last part of your small bowel. Dr. B C Shah will advise you which stoma is necessary and the reasons for this.

Colostomies are often described by the section of colon they are made from. They can be called transverse, descending or sigmoid colostomies. These are all technical terms used by surgeons but in practice, the way you care for any of these will be the same.

Living with a colostomy

If you need a colostomy, you may initially be concerned that your day-to-day activities will be restricted and that others will notice you are wearing a colostomy bag.

Modern colostomy equipment is both discreet and secure and there is no reason why you should not be able to take part in activities that you enjoyed before having a colostomy. Furthermore, other people will only be aware that you have a colostomy if you decide to tell them.

Adjusting to life after having a colostomy can be challenging and for some people it can also be distressing. However, most people become accustomed to it over time without experiencing the symptoms that made it necessary in the first place.

It is important to follow the recommendations given to you by the stoma nurse about the use of equipment to avoid problems and possible complications.

Why a colostomy is necessary

Some of the most common reasons for having a colostomy are explained below.

Bowel cancer

If a section of the colon is removed, a temporary colostomy is often used to allow the rest of the colon to heal. The healed colon is then rejoined and the colostomy can be removed.

If the rectum is removed, it is likely that you will need to have a permanent colostomy. If the anus is removed you will also need to have a permanent colostomy.

Diverticulitis

Diverticulitis is a condition that causes small pouches to develop in the wall of the colon, called diverticula, which become infected and inflamed. This can cause stomach pain, high temperatures and vomiting.

It is initially treated using antibiotics but if you have repeated episodes of diverticulitis, it is usually recommended that the affected section of the colon is removed. You may need a temporary colostomy while the remaining colon heals.

Crohn’s disease

Crohn’s disease is a condition that causes inflammation of the digestive system.

If Crohn’s disease does not respond to medical treatment, it may be necessary to remove a section of the colon and perform a temporary or permanent colostomy.

Bowel obstruction

Severe constipation, bowel cancer, a diseased colon or a hernia can cause the bowel to become blocked.

A bowel obstruction can become a medical emergency because there is a risk that the bowel could split, causing infection and internal bleeding.

In some cases it may be necessary to remove some of the colon and perform a temporary to permanent colostomy. If the entire colon is removed, then either a temporary or permanent ileostomy may be required.

Bowel incontinence

Bowel incontinence is a condition where a person is unable to control their bowel movements.

A colostomy can be used as a last resort, if all other medical and surgical treatments prove unsuccessful.

Injury

If a part of the colon needs to be removed following an injury, such as a knife or gunshot wound, a colostomy may need to be performed. The colostomy is usually temporary but in some cases can become permanent.

How a colostomy is performed

Before carrying out a colostomy, it is first necessary to remove the section of the colon that is affected. 

The surgery can be carried out in two ways:

• As an open operation (laparotomy), where the surgeon makes an incision in the abdomen to remove the affected section of colon
• As laparoscopic (or keyhole) operation, where the surgeon makes smaller incisions and uses a miniature video camera and surgical instruments to remove the affected section of colon

Where possible, keyhole surgery is the preferred treatment option because research has shown that patients recover more quickly from it and have a reduced risk of complications.

However, in emergency situations, such as a bowel obstruction, the staff and equipment that are needed for a keyhole operation may not be available, so an open operation will need to be performed.

Types of colostomy

There are two main types of colostomy operations.

They are:

• A loop colostomy
• An end colostomy

These are described in more detail below.

Loop colostomy

During a loop colostomy, the colon above the affected area is diverted and a loop of colon is pulled out into your abdomen as a colostomy (stoma). The stoma will have two openings but you may not be able to see both.

One opening will be the active end, where the waste products come from, and the other opening is the other end of the bowel that goes down to your rectum. This stoma is usually on the left-hand side of your abdomen, below your belt line.

These stomas are created by cutting a hole in the skin of your abdomen, pulling through a small section of your colon and stitching it into place. This is done under a general anaesthetic so you will be asleep during surgery and will not feel any pain.

The stoma will appear quite large at first as it will swell due to the effects of surgery. The stoma will usually shrink in size for six to eight weeks. After eight weeks it will stay this size.

It will be red in colour and moist. The stoma has no nerve endings so it isn’t painful to touch. The stoma may bleed when it is touched, but this is entirely normal and no cause for concern. The stoma will have sutures securing it in place. These are designed to dissolve and will fall out over time.

A loop colostomy is usually a temporary procedure which is used to treat conditions such as diverticulitis, Crohn’s diseaseand bowel cancer.

The remaining section of colon is either sealed and left in place or, if the colostomy is permanent, removed.

End colostomy

During an end colostomy, the colon above the affected area is diverted and one end of the colon is pulled out onto your abdomen as a colostomy (stoma). The stoma will have one opening and the waste products will pass through this opening. The other end of the colon which goes down to your rectum is left inside your abdomen. This stoma is usually on the left-hand side of your abdomen, below your belt line.

End colostomies are often permanent, although temporary end colostomies are sometimes performed as an emergency to treat bowel obstructions, colon injuries or bowel cancer.

The waste products produced by an end colostomy or loop colostomy are often very similar. The waste comes in the form of soft faeces (poo), which has been softened by water absorbed in the remaining part of the colon. The consistency of the waste can be affected by diet, so if you are dehydrated your faeces may be harder.

You can still experience constipation and diarrhoea. As the waste is formed you will use a closed appliance which cannot be emptied. You will have to change the colostomy appliance between one to three times a day.

If you have a transverse colostomy the output will be quite loose. If this is the case you may have to use a drainable appliance which will need emptying several times a day and changing every day or two days.

Some people who have a colostomy have a regular and predictable output in the same way that many people often experience regular bowel movements. If this is the case, you may not need to always wear a standard size colostomy bag. However, as occasional leakages can occur, it is recommended that you wear a small stoma cap.

Irrigation is an alternative to using a colostomy bag. This is where you wash your colon out with water every one to two days and collect the waste products in a sleeve.

Recovering from a colostomy

When you wake up after having a colostomy operation, you may be attached to several different devices, including:

• An intravenous drip, to provide your body fluids
• A catheter, which is a tube that is inserted into your bladder to remove urine
• Oxygen mask or nasal cannula, to help you breathe

These will be removed as you recover from the surgery.

A colostomy bag will be placed over your stoma (opening in your abdomen). This appliance will be clear so the stoma can be easily monitored and easily drained when the stoma first starts working. This first appliance is not likely to be the one you go home with.

Going home

Most people are well enough to leave hospital five days after laparoscopic surgery and 7-10 days after open surgery.

It’s important to avoid any strenuous activities at home that could place a strain on your abdomen, such as lifting heavy objects. Dr. B C Shah will advise you about when it is safe to resume such activities.

In the first few weeks after your operation, you may find that you experience excessive flatulence (gas), and that the discharge from your stoma is unpredictable. However, this should start to improve as your bowel recovers from the effects of the operation.

Colostomy reversal

If you have a temporary colostomy (usually a loop colostomy), further surgery will be needed to reverse it.

You will normally have to wait at least three months after the initial surgery. However, it can be longer if you require further treatment such as chemotherapy or you haven’t recovered from the stoma-forming surgery. There’s no time limit to have the stoma reversed. Some people may live with their colostomy for several years before it is reversed.

In some cases, reversing a colostomy may not be recommended. For example, if the muscles that control your anus (sphincter muscles) were damaged after surgery, reversing the colostomy may mean that you are unable to control your bowel movements. This could cause bowel incontinence.

If your colostomy can be reversed, it will be carried out when you are in good health and your bowel has fully recovered from the effects of the initial surgery.

Reversing a loop colostomy is a relatively straightforward process. An incision is made around the stoma to allow the Dr. B C Shah to gain access to the inside of your abdomen. The upper section of your colon (above the stoma) is reattached to the remaining section of your colon that was below the stoma. The incision is then sealed.

It is also possible to reverse an end colostomy. However, more invasive surgery is required because Dr. B C Shah will need to gain access to a larger section of your abdomen. Therefore, this type of surgery will require a longer recovery time and has a greater risk of complications.

You will be able to leave hospital once your have recovered from the effects of your stoma reversal. It may take some time before you resume normal bowel function and routine. Some people experience diarrhoea, though this normally resolves with time.

Some people may experience a sore anus initially after the reversal. This will be until the anus becomes used to having stools pass through it. If this occurs you can use common barrier creams, such as sudocream, as protection.

The reversal operation is usually a much smaller procedure then the initial stoma-forming surgery. However it will still take you several weeks to recover and return to all your normal activities.

Living with a colostomy

In the first few weeks after having a colostomy operation, it is likely that you will be put on a low-fibre diet. This is because surgery causes your bowels to swell, making it difficult to digest fibre. After the swelling has subsided (usually around eight weeks), you will be able to resume a normal diet.

Diet

As you recover you can start to eat a healthy balanced diet that includes plenty of fresh fruit and vegetables (five portions a day).

You should be able to return to the diet you previously enjoyed. If you had a restricted diet you should be able to reintroduce those foods back into your diet that you previously avoided.

Colostomy equipment

There is a wide range of colostomy appliances available, including:

• A one-piece pouch: bag and flange (part that sticks to your skin) are joined together. The appliance is removed when full and disposed of
• A two-piece pouch: the bag and flange are separate; they are joined together by a connection; the flange can be left on your skin for several days and the bag removed and disposed of several times a day

Dr. B C Shah will help you to choose the most suitable appliance for you.

To help reduce skin irritation, colostomy appliances are made from hypoallergenic (non-allergic) material, and contain special filters that ensure that the appliance does not release any unpleasant odours.

There are also additional products that can make living with a colostomy more convenient, including:

• Support belts and girdles
• Deodorisers that can be inserted into your appliance
• Protective skin wipes
• Adhesive remover sprays
• Protective stoma rings
• Specially designed underwear and swimwear

Dr. B C Shah will be able to advise you on the most appropriate equipment to manage your colostomy successfully.

Irrigation

Irrigation is an alternative to wearing a colostomy appliance. It involves washing out your colon with water either every day or every other day.

This involves gently inserting  a small device into your stoma and attaching it to a bag full of water and an irrigation sleeve, which acts in a similar way to a colostomy pouch.

You slowly move water into your colon so that it washes it out and moves the stools into the irrigation sleeve. The equipment can be disposed of once the process is complete. A cap is used to cover your stoma in between irrigations.

Advantages of irrigation include:

• You choose when you want to perform irrigation.
• You don’t have to wear a colostomy appliance (but may have to wear a small cap).
• You should be able to enjoy a more varied diet.
• You should experience less flatulence (gas).

Disadvantages of irrigation include:

• It’s a time-consuming process that takes 45 to 60 minutes to complete, usually on a daily basis.
• To achieve the best results, irrigation should be carried out at the same time every day which could cause you problems when you are away from home on holiday or with work.

Also, while some people don’t have any problem with irrigation, others find it unpleasant. It is possible to go back to using a colostomy pouch if you find that irrigation is not suitable for you.

Irrigation may not be possible in some circumstances. For example, people with Crohn’s disease or diverticulitis are unable to irrigate their colon as it is too damaged. Irrigation is also not suitable for people who are having a course of chemotherapy or radiotherapy.

Irrigation probably isn’t advisable for young children as it’s quite time-consuming.

Smell & wind

Many people worry that their colostomy will give off a smell that other people will notice.

All modern appliances have air filters that have charcoal in them. The charcoal is an odour eater, therefore this neutralises the smell. Most people will be aware of the smell of their colostomy because it is their own body. However, someone standing next to you will not be able to smell the stoma.

Immediately after your surgery your colostomy will make excess wind and noise. This will slowly reduce as your bowel recovers.

Dr. B C Shah can advise you of products that you can use to help reduce any smell and dietary advice to reduce wind.

Medication

Many medicines are designed to dissolve slowly in your digestive system. Having a colostomy shouldn’t alter the effectiveness of your usual medication. If you do notice any tablets in your appliance, notify Dr. B C Shah who will recommend an alternative medication for you to take.

Exercise

In the weeks following surgery, it is usually recommended that you do some gentle exercise to help you recover.

How you recover will determine how much exercise you can do. If you feel any pain, stop immediately.

Work

Once your bowel has healed, there is no reason why you can’t return to work. If your job is particularly strenuous and involves a lot of heavy lifting, you may need to wear a support belt or a girdle. Dr. B C Shah can advise you about this.

It’s likely to take several months before you’re ready to return to work. It you’ve had laparoscopic surgery you may be able to return to work sooner than after an open operation. However, it all depends on how you recover and the type of work you do. Whenever you do return you are likely to find it very tiring. It’s a good idea to discuss the potential options with your employer before having a colostomy operation.

Some employers may be happy to provide a degree of flexibility, such as allowing you to work part-time or at home, until your strength improves. Your employer may also be able to provide additional support, such as giving you access to changing facilities or adjusting your work responsibilities so that you don’t have to do lots of heavy lifting.

You don’t have to tell your work colleagues about your colostomy (unless you want to). Some people find it’s a good idea to tell one person in your workplace in case you need any support or advice.

Travel

There’s no reason why you can’t travel freely when you’ve had a colostomy, although you will probably need extra time when planning your journey.

Most stoma companies have a small information leaflet that you can carry with you at all times, which is available in several different languages.

Dr. B C Shah can give you advice about travelling with a stoma.

Sex

There are several practical issues that could arise after having a colostomy, which could have an impact on your sex life and your relationships.

Women

Women who have had their rectum removed, may find that having sex in the traditional “missionary position” is painful because the rectum no longer supports the vagina during sex. Trying different positions may help.

After surgery, many women also find that their vagina is much dryer which can also make sex uncomfortable. Applying a lubricating jelly before having sex may help.

Having weight placed on your stoma during sex can be painful, so you may want to avoid positions that could cause pain. Alternatively, you could protect the stoma with a cushion or pillow.

Dr. B C Shah will be able to give you more advice.

Men

Following a colostomy, some men find that the blood supply and nerve endings to their penis have become damaged. This can make it difficult getting or maintaining an erection (erectile dysfunction).

There are several ways to treat erectile dysfunction, including taking a medication called sildenafil, which helps increase the blood supply to the penis.

Other, sex-related issues

Aside from the practical issues, you may be concerned about body image, self-confidence and how your partner may react to your colostomy, which can also have an impact on your sex life.

However, it’s important to stress that many people who have a colostomy enjoy good sex lives but it can take several months to build up the confidence and trust to make this possible.

If you have a long-term partner, you may want to ask them if they want to see your stoma and colostomy equipment. Some people’s partners want to take an interest but others may find it too upsetting, at least in the short-term. There is no right or wrong way to react so try not to take a refusal as a personal rejection.

If the appearance of your stoma and colostomy equipment is off-putting during sex, you can always cover them with a nightgown or boxer shorts.

Other tips that may help improve your sex life include:

• Changing your appliance before having sex
• Changing your appliance to a small stoma cap before having sex
• Covering the appliance with a satin or cotton cover (if the feel of the appliance against your skin is a distraction during sex)
• Keeping your sense of humour: embarrassing mishaps often occur during sex, whether or not you have a colostomy.

Complications of a colostomy

Rectal discharge

People who have had a colostomy that has left their rectum and anus intact may experience a discharge of mucus from their rectum. Mucus is a liquid that is produced by the lining of the bowel and acts a lubricant, helping the passage of stools.

The discharge can occur as the lining of the bowel will continue to produce mucus even though it no longer serves any useful purpose. The longer the length of the remaining section of your bowel, the more likely you are to experience rectal discharge.

The mucus can vary from a clear “egg white” to a sticky, glue-like consistency. If there is blood or pus in the discharge, contact Dr. B C Shah because it may be a sign of infection or tissue damage.

Managing the discharge

The mucus can either leak out of your rectum and anus or build up into a ball which can become uncomfortable.

The pattern of rectal discharge can vary in each individual. Some people experience episodes every few weeks, while others experience several episodes a day.

Many people find that the most effective method of managing rectal discharge is to sit on the toilet each day and push down as if passing a stool. This should help remove any mucus that is located in the rectum and prevent it building up into a ball.

However, some people find it hard to remove the mucus in this way because they have reduced sensation in their rectum as the result of surgery.

If this is the case, contact Dr. B C Shah because you may require further treatment.

One treatment option is to use glycerine suppositories that you insert in your anus. When the capsules dissolve, they make the mucus more watery so that it’s easier to get rid of.

In some cases, the mucus can irritate the skin around the anus. Using a barrier skin cream should help. You may need to try a few before you find one that works for you. Your pharmacist can advise you about the different creams available.

Some people have reported that eating certain foods increases the production of mucus. However, there is no scientific evidence to support this, You may want to consider keeping a food diary for a few weeks to see whether certain foods could be linked to an increase in the production of mucus.

Parastomal hernia

A hernia occurs when an internal part of the body, such as an organ, pushes through a weakness in the muscle or surrounding tissue wall.

In cases of parastomal hernia, the intestines push through the muscles around the stoma resulting in a noticeable bulge under the skin. People with colostomies have an increased risk of developing parastomal hernias because the muscles in their abdomen have been weakened during surgery.

Effective ways of preventing a parastomal hernia developing include the following:

• Wearing a support belt or underwear
• Avoiding heavy lifting and straining
• Maintaining a healthy weight, because being overweight or obese can place additional strain on your abdominal muscles

Parastomal hernias aren’t usually painful, but they can make holding the colostomy appliance in place, and changing it, more difficult.

Most hernias can be managed conservatively (without the need for surgery) with advice and support from your stoma care nurse. In some instances surgery may be required to repair the hernia. However, even after surgery the hernia can reoccur.

Alternatives to a colostomy

An ileo-anal pouch is an alternative to having a colostomy. It is created from the end of the small intestine, which is known as the ileum. The procedure involves removing the colon and the rectum but not the anus.

The pouch is joined to the anus so that your bowel actions can be controlled in the usual way. The pouch stores waste material until you go the toilet.

The procedure

The operation is usually carried out in two stages. Firstly, your colon and rectum are removed before the pouch is created and joined to your anus. It is usually necessary to let the area around the pouch heal before it is used, so the end of the small intestine is connected to a stoma (opening) in your abdomen. This procedure is known as an ileostomy.

After a couple of months, a second, smaller operation is carried out to close the ileostomy. It can be possible for the operation to be performed without creating a temporary ileostomy.

Advantages and disadvantages

The advantage of having an ileo-anal pouch is that you will not have a permanent stoma in your abdomen or need to use a pouch or regular irrigation. A disadvantage of having an ileo-anal pouch is that you will pass stools very frequently, often up to 20 times a day, until your pouch has fully expanded.

This usually settles down after six months to a year. However, the number of bowel movements varies: some people will only need to empty their pouch twice a day whereas others may have to empty it six to eight times a day.

Accidental leakages from the pouch are also common during the first few weeks after the operation and the pouch can become infected, which is known as pouchitis.

Symptoms of pouchitis include:

• Diarrhoea, which is often bloody
• Abdominal pains
• Stomach cramps
• Dehydration
• High temperature (fever) of 38C (100.4F) or above

Pouchitis can usually be successfully treated with antibiotics.

An ileo-anal pouch may not be suitable for everyone. For example, it isn’t usually recommended for people with Crohn’s disease because there’s a risk that the inflammation associated with the condition may spread into the pouch.

An ileo-anal pouch may also not be suitable for older people who are over 70 years old because they usually don’t have sufficient muscle tone to make effective use of the pouch.