Monday, August 30, 2021

Supporting patients with stomas

 - Jennifer Middleton, MD, MPH

Family physicians are likely to care for patients with colostomies and ileostomies, so comfort with both the basics of stoma care and the common psychosocial challenges of managing a stoma are a must. Patients may have temporary colostomies for several reasons, including the need to divert stool away from the perineum for surgical procedures and with bowel resections for diverticular disease or malignancy. Patients with cancer, severe fecal incontinence, inflammatory bowel disease, and/or recurrent diverticular disease may have permanent colostomies or ileostomies. 

Patients should receive instructions from their colorectal care team about the frequency of emptying and changing their stoma bags. Some patients will be advised to empty their stoma bag 1-3 times a day and will then replace the bag every 2-4 days; some patients will be advised to simply replace the bag when full every 1-2 days. The odor of stool from a stoma can be more intense than with usual defecation, and patients may want to choose an air freshener product to keep handy during bag emptying and changing. Patients should be prepared for the potential of bag leaking by either carrying or keeping nearby an extra set of supplies (new ostomy bag, adhesive remover, new adhesive, small trash bag/plastic bag for disposal).

There are different types of ostomy bag systems and a wide variety of products to protect the skin around the stoma (including powders and barrier wipes). Although colorectal care providers usually manage product recommendations and orders, keeping track of the products your patients are using will help if they ever need you to reorder them. Familiarity with these supplies and general management of ostomy bags can also lead to more meaningful conversations with patients about ostomy management. This 5-minute video gives an overview of emptying and changing ostomy bags. Healthy stomas are pink or red and often have a somewhat raw or abraded appearance. Skin care around the stoma site is important, and patients should be checking the skin around the stoma with every bag change. If patients are experiencing skin irritation, encourage them to should reach out to their colorectal team to discuss skin care product options; if their stoma is blue, purple, or tender, urge patients to reach out to their colorectal care team immediately for evaluation.

Having provided care for a family member with a stoma, I can personally relate to the challenges of adapting to a colostomy or ileostomy. Talking about stool and bowel problems is often stigmatized, and, consequently, patients may not feel that they can discuss the challenges of dealing with a stoma with friends and family. It's not surprising that persons with a stoma have higher rates of depression and social isolation compared to the general population. Dyspareunia and erectile function are also more common in patients with stomas. This article contains several pragmatic tips for managing situations such as returning to work, traveling, and intimacy. Patients can also find positive depictions of life with a stoma on social media and connect with both local and online support groups for "ostomates." 

Although stomas may seem intimidating at first, family physicians are more than capable of learning the basics of stoma care and supporting patients with stomas throughout their experience.