Overview
Definition:
Ileostomy prolapse occurs when a portion of the ileum protrudes through the ileostomy stoma
Repair aims to reduce the prolapsed segment and secure the stoma to prevent recurrence.
Epidemiology:
Ileostomy prolapse is a common complication, occurring in 5-10% of patients with ileostomies
Risk factors include obesity, increased intra-abdominal pressure, and inadequate stoma construction.
Clinical Significance:
Prolapse can lead to leakage, skin irritation, stoma ischemia, and patient distress, significantly impacting quality of life
Prompt and effective management is crucial for patient well-being and preventing further complications.
Clinical Presentation
Symptoms:
Visible protrusion of the bowel through the stoma
Discomfort or pain at the stoma site
Difficulty applying ostomy appliances
Changes in stoma output volume or consistency
Bleeding from the stoma.
Signs:
Edematous, erythematous bowel segment protruding from the stoma
The length of prolapse can vary
Stoma can be dusky or ischemic in severe cases
Tenderness on palpation
Reduced or absent peristalsis if ischemic.
Diagnostic Criteria:
Diagnosis is primarily clinical, based on visual inspection of the stoma and patient-reported symptoms
No specific lab or imaging criteria, though imaging may be used to rule out other abdominal pathologies.
Diagnostic Approach
History Taking:
Duration and onset of prolapse
Previous stoma surgeries
Any history of abdominal surgery or increased intra-abdominal pressure
Patient's ability to manage stoma appliance
Presence of pain or bleeding
Recent changes in bowel habits.
Physical Examination:
Careful inspection of the stoma and surrounding skin
Assess the degree of prolapse and viability of the protruding bowel
Palpate for tenderness and check for peristalsis
Assess the fit of the ostomy appliance
Examine the abdominal wall for hernias.
Investigations:
Generally, no specific investigations are required for diagnosis
If bowel ischemia is suspected, a complete blood count (CBC) may show leukocytosis
Imaging like CT scan or ultrasound may be considered if there is uncertainty about the diagnosis or to assess for other intra-abdominal pathology or strangulation.
Differential Diagnosis:
Other causes of bulging around the stoma include peristomal hernia, parastomal abscess, or granulation tissue
Prolapse of other intra-abdominal contents (e.g., omentum) is rare but possible
Differentiating from simple peristomal hernia requires assessment of the bowel protruding through the stoma itself.
Management
Initial Management:
For acute, reducible prolapse: Manual reduction by gently pushing the prolapsed bowel back into the abdominal cavity
Application of a lubricated compress or specialized appliance
Patient education on stoma care and when to seek medical attention.
Surgical Management:
Surgical intervention is indicated for recurrent prolapse, irreducible prolapse, signs of ischemia or strangulation, or significant impact on quality of life
Options include: 1
Resuturing the stoma with plication of the bowel
2
Revision of the stoma with creation of a narrower opening
3
Relocation of the stoma
4
Repair of associated peristomal hernia, often with mesh reinforcement.
Postoperative Care:
Pain management
Antibiotic prophylaxis
Monitoring for stoma viability, output, and signs of infection
Gradual return to oral intake
Strict fluid balance monitoring
Education on proper stoma care and appliance changes
Follow-up appointments to assess stoma function and healing.
Conservative Management:
May be considered for small, reducible prolapses in asymptomatic patients or those who are poor surgical candidates
This includes careful stoma appliance management and patient education on self-reduction techniques
Close monitoring is essential.
Complications
Early Complications:
Bleeding from the stoma
Infection at the stoma site
Stoma ischemia or necrosis
Recurrence of prolapse
Injury to the bowel during reduction or surgery.
Late Complications:
Recurrent prolapse
Peristomal hernia
Stoma stenosis
Skin breakdown around the stoma
Adhesions
Fistula formation
Long-term difficulty with appliance adherence.
Prevention Strategies:
Proper stoma site selection
Creation of a well-matured, robust stoma
Avoiding excessive tension on the bowel
Adequate fixation of the bowel to the abdominal wall
Patient education on weight management and avoiding straining
Prompt management of early prolapse symptoms.
Prognosis
Factors Affecting Prognosis:
Degree of prolapse
Presence of ischemia or strangulation
Patient's overall health status
Success of surgical repair
Adherence to postoperative care and follow-up.
Outcomes:
Successful surgical repair generally leads to resolution of symptoms and improved quality of life
Recurrence rates vary depending on the technique used and patient factors
Long-term stoma function and patient satisfaction are important outcomes.
Follow Up:
Regular follow-up is essential, especially after surgery, to monitor stoma function, assess for recurrence, and address any long-term complications
This typically involves clinic visits with stoma care nurses and the surgical team.
Key Points
Exam Focus:
Recognize prolapse as a common complication of ileostomy
Understand indications for surgical repair (ischemia, recurrence, symptoms)
Differentiate between prolapse and peristomal hernia
Know common surgical techniques: stoma revision, plication, relocation.
Clinical Pearls:
Always assess stoma viability if prolapse is present
Manual reduction is the first-line treatment for reducible prolapse
Consider mesh reinforcement for associated peristomal hernias during repair
Patient education is paramount in preventing and managing prolapse.
Common Mistakes:
Delaying surgical intervention when indicated
Aggressive manual reduction that could injure the bowel
Inadequate fixation of the bowel during stoma creation or revision
Underestimating the impact of prolapse on patient quality of life.