The stem
A 58-year-old man is on day 4 after an emergency laparotomy. You are shown his abdomen.
The equipment
The examiner’s questions
Question 1What is this, and how can you tell what kind it is?Show the model answer
A stoma. It is in the right iliac fossa and has a spout about 2.5 cm high with a single opening, so it is most likely an end ileostomy. A colostomy is usually in the left iliac fossa and flush with the skin. A loop stoma has two openings and may have a supporting rod in the early days.
Question 2Why does an ileostomy have a spout?Show the model answer
Small bowel content is liquid and contains digestive enzymes that damage the skin. The spout lets the output drop straight into the bag without touching the skin.
Question 3What output do you expect, and when is it a problem?Show the model answer
An ileostomy usually produces about 500 to 1,000 mL a day of liquid to semi-solid output. More than about 1.5 to 2 litres a day is a high-output stoma, which causes dehydration, kidney injury and low sodium, potassium and magnesium. Measure the output, replace fluid and electrolytes, and consider loperamide.
Question 4What are the complications of a stoma?Show the model answer
Early: ischaemia and necrosis (the stoma turns dark), retraction, high output and skin irritation. Late: parastomal hernia, which is the commonest, prolapse, stenosis and psychological problems with body image.
After you answerThe teaching pointShow
Before an elective operation, a stoma nurse marks the site: within the rectus muscle, away from skin folds, scars, bony prominences and the belt line, and where the patient can see it.
The drawings were made for this site. The patients are written for teaching and are not real.