Module 1883

Clinical

Module 1883 Stoma care: complications and advice From this pharmacy CPD module on stoma you will learn about: • The devices used in stoma care • The different problems and complications associated with it • The advice you should provide about prescribed and OTC medicines

THOMAS CORBETT, PHARMACIST

• the pouch/bag collects output from the stoma

Charity Stomawise estimates 13,500 people have stoma surgery in the UK each year. These may be patients with inflammatory bowel disease, colorectal cancer, an invasive infection, or who had an injury affecting the gastrointestinal region. But what precisely is a stoma? Fittingly, the word stoma (plural: stomata) comes from the Greek word meaning mouth or opening. The medical explanation refers to a stoma as a surgically created opening on the surface of the abdomen that diverts the flow of faeces or urine into an external pouch located outside of the body. These openings may be created temporarily or permanently. There are various types of stoma, but the most common are: • colostomy − part of the colon (the large intestine) is diverted to the surface to create a stoma • ileostomy − part of the small intestine is diverted to the surface to create a stoma • urostomy − the tubes that usually carry urine out of the kidneys are diverted to the surface (a part of the small intestine is removed to use as an extension to join the ureters to the surface). Community pharmacists act as a source of support to people with stomas. They also provide a supply of various devices that are required for stoma maintenance:

(stools or urine) and is fitted with external filters that allow air to be expelled from the bag while absorbing odours (helping prevent inflation) • the skin barrier is the adhesive component that sticks to the skin around the stoma • the flange is the plastic ring component of both the pouch and the skin barrier that facilitates their attachment; the pouch and the skin barrier must be of the same size and product range to fit together; for some patients, flanges need to be cut to size (this is typically completed by the supplier). In addition, one-piece pouches – where the pouch and the flange are already joined together – are available. Additional supplies can include wipes, disposal bags, absorbing agents (placed in the pouch to solidify liquid stools), adhesive removers, belts (to hold the bag in place), deodorants and skin barrier creams. Patients with a permanent stoma are entitled to a medical exemption certificate for NHS prescription charges. Colostomy bags need to be changed between one and three times per day, but (if necessary) there are drainable pouches available that can remain in place for a day or more. The output from ileostomies contains more liquid than faecal matter, and ranges from a watery to a porridge-like consistency. Because of

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this, ileostomy bags have a small opening in the bottom to allow drainage directly into a toilet. The bag can then be replaced and disposed of in the general rubbish every one to two days. Urostomy bags also have a tap at the bottom to facilitate drainage. The frequency of drainage will vary between people and based on fluid consumption. The patient’s stoma care team can advise on the frequency of bag changes.

skin or internally within the tummy; this could be due to a poor choice of bag/appliance and the patient should consult their stoma care team • dehydration − as ileostomy patients do not reabsorb water from their large intestine they are more susceptible to dehydration; they should drink plenty of water, especially during hot weather or when undertaking exercise.

Stoma care

Skin care

Poor stoma care is associated with complications, such as: • stoma blockage − this can arise due to a buildup of food, and can be prevented by chewing food thoroughly, drinking plenty of fluids and avoiding eating large amounts at one time • leakage − stoma output may leak around the

Good skin care is important for all stoma patients, as the skin around the stoma can become irritated and sore. In order to prevent irritation, the adhesive plate must fit snugly around the stoma, so that the skin around the opening is not exposed to output. In addition, the adhesive plate must not be too small, as this can damage the stoma.

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Harsh irritant cleansers should be avoided; instead, patients should regularly clean the area using mild soap and water. Burning or itching skin is a sign that the patient’s equipment needs to be changed. If a large area of skin becomes inflamed, the patient’s stoma care team will be able to prescribe treatments – such as a cream, powder or spray – to help treat this.

Diet and food In the first month or two after stoma surgery, patients are generally advised to follow a low fibre diet in order to avoid blocking the stoma. After this time, a normal diet can be resumed and the patient should aim to eat healthy, balanced meals. A healthy eating guide for people who had a colostomy is available from the Colostomy Association at tinyurl.com/CDhealthyeat.

An unlicensed high dose of the antimotility drug loperamide, or the bile acid sequestrant cholestyramine are also sometimes used to manage diarrhoea. Other drugs which may be prescribed by the patient’s stoma care team include proton pump inhibitors or octreotide (unlicensed indication) in order to reduce intestinal secretions; or a growth hormone called teduglutide that helps increase intestinal absorption. Drug absorption in stoma patients Due to the shortened intestinal length in stoma patients, drug absorption can be impaired to varying degrees. This is more of a problem in ileostomy patients, as the majority of drug absorption occurs in the small intestine. If incomplete absorption occurs, prescribers

may need to use higher doses or an alternative route of administration. Enteric-coated and modified-release medicines are unsuitable for ileostomy patients as there may not be sufficient release and absorption of the drug. Soluble tablets, liquids, capsules or uncoated tablets are more suitable due to their quicker dissolution. If incomplete absorption is suspected, the contents of the patient’s ostomy bag can be checked for any remnants.

Non-prescription medicines Community pharmacists can be a vital source of advice about the safe and effective use of nonprescription medicines in stoma patients. To the right are a range of factors that need to be considered when advising on the use of nonprescription medicines in stoma patients.

Advice about medicines Constipation It is not uncommon for colostomy patients to experience constipation. Increasing fibre (after initial treatment) in the diet and drinking more fluids can be recommended, as these are usually the underlying cause. Laxatives should generally be avoided in ileostomy patients as they can rapidly lead to a problematic loss of fluids and electrolytes. However, if drug treatment is necessary, a bulk forming laxative (such as ispaghula husk) can be tried. Diarrhoea Diarrhoea is common in patients who have a shortened bowel, due to less opportunity for absorption of water. Very spicy foods or large amounts of beer can sometimes be the cause, as these may irritate the lining of the digestive tract. Oral rehydration salts (such as Dioralyte) are sometimes used to promote adequate absorption of fluid in the gastrointestinal tract, thereby reducing the fluidity of stools.

Co-codamol – you should advise patients to avoid using codeine as it can lead to constipation. If a patient required an analgesic, then paracetamol should be recommended. Aspirin and other non-steroidal antiinflammatory drugs – these may cause gastric irritation, which is problematic in patients with a stoma. If these medicines cannot be avoided, then their stoma output should be monitored for blood. Loperamide – non-prescription doses are not effective in patients with colostomy and ileostomy; it may be necessary to refer the patient for further advice and treatment (see Diarrhoea, left). Iron – preparations containing iron may lead to a change in dietary status, either causing constipation or diarrhoea. In addition, they may lead to peristomal skin (the area surrounding the stoma) irritation and inflammation. Aluminium and magnesium – these preparations are well documented as causing gastrointestinal side effects (for example, aluminium may cause constipation and magnesium may cause diarrhoea) and as such should be avoided. Calcium preparations – medicines such as Adcal and Calcichew Forte should be avoided in patients with urostomy as calcium stones can form due to excess calcium. Further information on stoma care is available in the British National Formulary (BNF) at tinyurl.com/CDBNFstoma.

Pharmacy advice for stoma patients Community pharmacists should be aware of common ostomy-related problems in order to be a source of advice and reassurance for patients.

Modified-release drugs are unsuitable for ileostomy patients as they may not be absorbed in time


Pancaking This occurs when stool sits at the top of the bag and spreads out into a pancake shape, rather than dropping to the bottom of the bag, and can result in leakage. This most commonly occurs if there is not enough residual air in the bag and too much air is escaping through the external filter. Improper bag attachment is usually the cause.


Ballooning This refers to inflation of the bag and is usually prevented due to the external filter, but certain provocative foods may cause excess gas production. Patients who identify a causative food should avoid it when possible. Travel Before travelling abroad, patients must ensure that they are bringing a sufficient quantity of supplies to last for their entire trip. At least some of these supplies should be kept in hand luggage in case their checked luggage goes missing. They should also carry a letter from their GP stating that they need to keep their ostomy supplies and medicines in their hand luggage to avoid any difficulties, as ostomy appliances show up on airport security scanners. Travel certificates

can be obtained from ostomy manufacturers and outline what the appliance is. Patients who pre-cut their own bags should ensure this is done before they leave – due to restrictions for carrying scissors on aeroplanes and in other areas. Patients should also be pre-warned that their bags will inflate during flights due to changes in air pressure. This can be exacerbated by the consumption of carbonated beverages.

the muscles around the stoma can cause a hernia (the abnormal exit of an organ through the wall of the cavity in which it normally resides). Patients can swim and bathe with their bag in place; alternatively, plugs or caps are available for attachment in place of the bag. Special swimming costumes, designed to disguise the appearance of a prominent stoma, are also available for purchase. Further information is available from Colostomy UK at tinyurl.com/CDcolostHE.

Exercise The benefits of exercise are important for everyone, and ostomy patients can participate in most forms of sport and exercise. However, contact sports may pose a risk of injury, so the patient should discuss this with their stoma care team. Caution is also required with weight lifting activities, as straining

Sex Following recovery, ostomy patients will be able to resume their sex life, but they should be aware that they may find certain sexual positions uncomfortable. A smaller bag or a stoma cap may be used during sex if the patient prefers. Women may experience vaginal dryness following stoma

surgery, which can be alleviated with the use of lubricants. Sexual problems and pain are more likely when the rectum has been removed. Patients should not hesitate to seek advice from their stoma care team if they are concerned in any respect. Work Recovery can take several months following ostomy surgery, but there is no reason why patients cannot return to work if they wish. Duties may be very tiring at first, so fewer hours or lighter duties may be appropriate. Potential approaches can be discussed with their employer. Patients do not need to tell their colleagues that they have a stoma, but they may wish to tell at least one person in case they need support or advice.

Stoma care: complications and advice CPD

Take the 5-minute test online

What are you planning to learn? I want to learn more about stoma care, including the different types of stoma, the devices used and the complications associated with poor stoma care. I also want to learn about the advice that pharmacists can give to stoma patients about medicines use and common ostomy related problems. This learning will help me to improve my knowledge of stoma care and to be able to provide better, more effective advice to patients and carers.

1. It is estimated that 26,500 people in the UK require a stoma each year. True or false

How are you planning to learn it?

• I plan to find out more about colostomy and ileostomy on the NHS Choices website at • • • •

tinyurl.com/stomacare1 and at tinyurl.com/stomacare2. I plan to read more about urostomy on the Urostomy Association website at tinyurl.com/stomacare3. I plan to improve my knowledge of the different types of appliances available on the Stomawise website at tinyurl.com/stomacare4. I plan to read about sport and fitness after stoma surgery on the Colostomy UK website at tinyurl.com/stomacare5. I plan to find out more about healthy eating for people who have had a colostomy on the Colostomy UK website at tinyurl.com/stomacare6.

Give an example of how this learning has benefited the people using your services. I provided advice during a consultation about over-the-counter medicines suitable for a stoma patient.


2. A stoma is a surgically created opening on the surface of the abdomen that diverts the flow of faeces or urine into an external pouch. True or false

6. In the first month or two after stoma surgery, patients are generally advised to follow a high fibre diet. True or false 7. Enteric-coated and modified-release medicines are typically unsuitable for ileostomy patients. True or false

3. A colostomy is where part of the small intestine is diverted to the surface to create a stoma. True or false

8. Drug absorption may be impaired in stoma patients due to the shortened intestinal length. True or false

4. Patients with a permanent stoma are exempt from NHS prescription charges. True or false

9. Over-the-counter doses of loperamide are not effective in patients with colostomy and ileostomy. True or false

5. Colostomy patients are more susceptible to dehydration than ileostomy patients as they do not resorb water in the large intestine. True or false

10. Indigestion remedies are not recommended for ostomy patients, as aluminium salts cause diarrhoea and magnesium salts cause constipation. True or false
