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378 Rolstad and Wong
PATIENT SUPPORT
Patients with enterocutaneous fistulas are faced with numerous psychosocial is-
sues, important among which are independence, control, and concerns about the
future. Coping strategies used by these patients are varied. Intellectualization,
denial, confrontation, isolation, and rationalization are only a few. Supportive
counseling is a useful intervention for helping the patient to cope because it de-
creases the patient’s anxiety and some of his or her sense of isolation.
Effective technical management of the fistula is primary to patient
adaptation. Patients who have leakage and odor associated with their pouch-
ing systems are anxious and embarrassed. Therefore securing the pouching
system is the initial step toward patient support. Once the containment sys-
tem has been made secure, mobility and esthetic issues can be addressed.
Mobility is restricted when some pouching systems are used. An example
is that of the patient who is using suction to collect exudates. Immobiliza-
tion may lead to the secondary problems of pneumonia or pressure ulcers.
Attention to respiratory activity and pressure reduction on the bed are criti-
cal in preventing these problems. Suction or straight drainage can be dis-
connected during ambulation. However, the ongoing need for suction should
be re-evaluated frequently in order to respond to the concerns of patient
dignity and mobility. When pouching systems are used for fistulas over
long periods of time, opaque pouches or fabric pouch covers may be used.
This intervention decreases the perspiration associated with plastic and re-
moves the soiled pouch from view.
Restricted mobility and ongoing treatment threaten the patient’s indepen-
dence and lead to concerns about the future. All patients worry about their
ability to function normally. In addition, they are concerned about freedom to
interact in relationships with others. Loss of love and approval from significant
others is another important issue. The employed person may be worried about
loss of position and future income. Prolonged or numerous hospitalizations
threaten the person’s independence, finances, and emotional stability. In re-
sponse to these needs, supportive counseling with consistent caregivers is most
helpful. The collaborative approach also helps the caregivers, because the pri-
mary physicians and the ET nurse become primary support resources as they
help one another. In addition, a mental health professional is a useful support
to patients, whether for the short or long term.
Issues of control are common concerns for patients with fistulas. In
order to respond to these needs, patients and significant others are included
in teaching sessions from the outset. When patients understand the rationale
for interventions and participate in procedures, they recover a measure of
control. Initially, patients are encouraged to inform the nurse when the
pouch requires emptying. Later, they are asked to participate in skin care
and dressing changes or pouch assembly. When such physical participation
is not possible, the patient may take on the role of overseer and supervisor
of care. At discharge, the caregiver, whether patient or significant other,
Nursing Management of Fistulas 379
provides, in turn, a demonstration of these skills for the nurse. Follow-up
appointments for ongoing evaluation are scheduled with the ET nurse.
COST CONTAINMENT
This chapter has presented goals in care and approaches to management of
the fistula patient. Any discussion of cost recognizes that cost is a direct
result of resource consumption. Two of the most expensive resources in the
topical care of fistulas are product and labor. Critical decision making has
been recommended in order to avoid the trial-and-error method of product
selection. The trial-and-error approach usually produces half-used boxes of
numerous types of products stacked on a shelf in the patient’s room, while
other products are currently being tried. By making the best choices on the
basis of a sound rationale product usage and the labor required to complete
procedures will generally be decreased. A rule of thumb is to simplify. Clini-
cians may approach fistula management as a challenge to demonstrate com-
plex skills. While this may indeed be the case, the experienced clinician
knows that the most elegant solution is the simplest. Use of ostomy pouch-
ing equipment is usually the most inexpensive approach to managing fistu-
las. However, this may not be the best option for low-volume, odorless
fistulas. From a cost perspective, dressings changed three times a day are
inexpensive on a unit cost basis. However, the cumulative cost of product
is greater than applying an ostomy pouch and changing it every 3–7 days.
Further, the patient in hospital for 4 days will require 1 pouch change ver-
sus 12 dressing procedures from the nurse.
When the clinical situation presents a fistula with a large cutaneous
opening and high-volume output present, the cost of care will increase. An
access cap for a pouch and large adhesive surfaces dictate wound manage-
ment systems. Few alternatives exist that are appropriate and each is an
expensive choice per unit.
CONCLUSION
Intestinal fistulas present a complex problem for patients, nursing staff, and
physicians. These problems are often chronic in nature and involve both
inpatient and outpatient management. Integrated management led by the
enterostomal therapist will minimize patient suffering, decrease complica-
tions, and often hasten fistula healing.
REFERENCES
1. Rolstad BS, Bryant RA. Management of drain sites and fistulas. In: Bryant
RA, ed. Acute and Chronic Wounds. 2nd ed. St. Louis: Mosby, 2000:317–341.
2. Rolstad BS, Boarini J. Principles and techniques in the use of convexity.
Ostomy Wound Manage Nurs 1996; 42(1):24–34.
380 Rolstad and Wong
3. Catanzaro J, Serembus JF. High-tech wound and ostomy care in the home
setting. Crit Care Nurs Clin N Am 1998; 10(3):327–338.
4. Goldstein BG, Goldstein AO. Practical Dermatology. 2nd ed. St. Louis:
Mosby, 1997.
5. Gordon PH, Rolstad BS, Bubrick MP. Intestinal stomas. In: Gordon PH,
Nivatvongs S, eds. Principles and Practice of Surgery for the Colon, Rectum,
and Anus. 2nd ed. St. Louis: Quality Medical Publishing, 1999:1117–1176.
6. Scardillo J, Folkedahl B. Management of a complex high-output fistula. J
Wound Ostomy Continence Nurs 1998; 25:217.
7. Eakin M. Fistulas: a nursing challenge. Dimensions Oncol Nurs 1991; 5(3):
26–31.
8. Rolstad BS, Boarini J. Principles and techniques in the use of convexity.
Ostomy Wound Manage Nurs 1996; 42(1):24–34.
9. Sadler B, Froiland K. Obese patient with ileostomy management problems
related to fluctuating weight and changing peristomal contours. J Wound Os-
tomy Continence Nurs 2002; 29(3):164–169.
10. Skingley S. The management of a faecal fistula. Nurs Times 1998; 16:64–66.
11. Wound, Ostomy, Continence Nurses Society. Convex Pouching Systems: A
Fact Sheet for Clinicians. 2002. Wound, Ostomy, Continence Nurses Society,
Greenview, IL
12. Wiltshire BL. Challenging enterocutaneous fistula: a case presentation. J
Wound Ostomy Continence Nurs 1996; 23(6):297–301.
13. Faller NA, Beitz JM. When a wound is not a wound: tubes, draining, fistulae,
and draining wounds. In: Krasner DL, Rodeheaver GT, Sibbald RG, eds.
Chronic Wound Care: A Clinical Source Book for Heatlthcare Professionals.
3rd ed. Wayne, PA: HMP Communications, 2001:721–729.
14. Beitz JM, Caldwell D. Abdominal wound with enterocutaneous fistula: a case
study. J Wound Ostomy Continence Nurs 1998; 25(2):102.
15. Lange MP, Thebo LM, Tiede SM, McCarthy B, Dahn MS, Jacobs LA. Man-
agement of multiple enterocutaneous fistulas. Heart Lung: J Crit Care 1989;
18(4):386–391.
16. Davis M, Dere K, Hadley G. Options for managing an open wound with
draining enterocutaneous fistula. J Wound Ostomy Continence Nurs 2000;
27(2):118–123.
ADDITIONAL RESOURCES
Coloplast. http://www.amoena.ru/
ConvaTec, Inc. http://www.convatec.com
Hollister, Inc. http://www.hollister.com/us/products/ostomy/
Nu-Hope Laboratories, Inc. http://www.nu-hope.com/
Wound, Ostomy, Continence Nurses Society. http://www.wocn.org
Wound, Ostomy Continence Nursing Society. Guidelines for management: Caring for
a patient with an ostomy. 1998. Wound, Ostomy, Continence Society. Glenview,
IL.
Colwell JC, Goldberg MT, Carmel JE. Fecal and Urinary Diversions: Management
Principles. St. Louis: Mosby, 2004.
19
Diagnosis and Treatment
of Peristomal Skin Conditions
Najjia N. Mahmoud
Hospital of the University of Pennsylvania,
Philadelphia, Pennsylvania, U.S.A.
Brenda S. Bradley
Thomas Jefferson University Hospital,
Philadelphia, Pennsylvania, U.S.A.
INTRODUCTION
There are over 1.5 million patients with intestinal stomas in the United
States, and 100,000 new stomas are created yearly. Of these, 51% are co-
lostomies, 35% ileostomies, and 12% urostomies [1]. The development of
increasingly sophisticated stoma appliances and adhesives has mirrored a
growing interest in the dermatological complications associated with long-
term stoma management. Intestinal effluent, particularly ileostomy drain-
age, can be caustic and irritating. Chronic dermal exposure to proteolytic
enzymes, high alkaline content, and constant moisture leads to peristomal
skin damage. Ostomy trauma, folliculitis, and minor peristomal erythema
from exposure to adhesives are the most common complaints. Less com-
mon and perhaps more serious are peristomal problems stemming from under-
lying disease. Pyoderma gangrenosum and peristomal varices exemplify cu-
taneous manifestations of serious illnesses. Good peristomal skin care starts
with appropriate patient selection, knowledgeable stoma site marking to
avoid creases and folds, patient education, and treatment or correction of
underlying disease. Unfortunately, even strict adherence to these principles
may not eliminate all problems. Prompt and early recognition of small
breaks in the skin may allow the initiation of corrective measures that mini-
mize damage. Good surgical technique in most nonobese patients ensures
that a generous lip or protective nipple of mucosa is present on ileostomies.
Severe peristomal skin excorlation and ulceration may result from absence
of this protective feature. The consequences of a flush colostomy are not
quite as dire but can make appliance placement and sealing very problem-
381
382 Mahmoud and Bradley
atic, thereby leading to skin breakdown or irrigation from excessive manip-
ulation. In this chapter, important dermatological issues are discussed with
a focus on their diagnosis and proper management.
PERISTOMAL IRRITATION
Chemical Irritation
Stomal effluent leaking onto peristomal skin is the most common cause of
chemical irritation and peristomal dermatitis in general. Poorly functioning
ostomy devices and face plates, lack of proper patient education, and flush
or improperly placed stomas are the main culprits. Although the etiologies
of allergic contact dermatitis and chemical irritation are different, the re-
sults are the same. The peristomal skin appears reddened, itchy, weeping,
and excoriated, progressing to frank ulceration if left unchecked. The pro-
cess may be escalated by the patient’s scratching and infection can rapidly
ensue (Fig. 1). Ileostomy effluent has a high fluid component, is highly
alkaline, and contains a corrosive mix of proteolytic enzymes [2]. Even
slight imperfections in the fit of the stoma’s face plate can allow chyme to
seep under it and become trapped in contact with the skin. Placement of
the wafer over scars or creases is the usual problem and can be avoided by
preoperative marking of the stoma. Persistent oversizing of the wafer hole
can also contribute. A protective powder to ensure adhesion of the appli-
ance over moist skin or a light application of corticosteroid spray to areas
Figure 1 Ileostomy with extensive skin corrosion caused by leaking stoma appli-
ance.
Peristomal Skin Conditions 383
of erosion may be helpful in alleviating the pruritus and burning associated
with inflammation. Use of a skin sealant with a copolymer or plasticizing
agent without alcohol provides a thin protective film on the skin surface,
helps prevent skin stripping of the epidermis during adhesive removal, and
acts as a moisture barrier [3]. Skin barriers in the form of powders, pastes,
rings, and wafers are used to protect the peristomal skin from effluent,
create a level pouching surface, and treat peristomal skin loss. In severe,
moist, irritant dermatitis, meticulous skin cleansing with normal saline, lib-
eral application of a skin protectant ointment with dimethicone, and the use
of a convex wafer and pouch held in place with a belt may help facilitate
healing of the inflamed skin, especially when an adhesive barrier will not
stick.
It can be quite difficult in some patients to create a viable stoma with
a good lip of mucosa protruding above the skin. Obesity can create length
problems and make it difficult to bring loop stomas through the thick ab-
dominal wall, resulting in flush, retracted ostomies (Fig. 2). Tension can
result in ischemia and stomal retraction. Good surgical technique is impera-
tive in avoiding these pitfalls. Formation of a Brooke ileostomy for both
loop and end stomas is preventive. Adequate intestinal mobilization of well-
vascularized intestine minimizes retraction. Unfortunately, even successful
surgery can have troublesome consequences. Rapid or excessive weight
gain can recess the stoma into fatty tissue folds, resulting in a flush, hard-
to-pouch ostomy. There have been a number of reports of the use of local
peristomal liposuction in this instance to create a “platform” on which to
Figure 2 Failure to maintain a seal around a flush stoma has resulted in irritation
of the peristomal skin.
384 Mahmoud and Bradley
place the wafer [4]. Using semiflexible pouches with varying degrees of
convexity is probably the best initial step and is the most common solution
to slightly retracted or just-visible stomas [5]. Stomas that are severely re-
tracted or not amenable to convex pouching need to be surgically revised
either locally or by laparotomy. Local revision is accomplished by incising
the stoma at the mucocutaneous junction, dissecting circumferentially down
to the fascia while avoiding injury to the mesentery, freeing up the intestine
from the surrounding fascia, and pulling up additional bowel to fashion a
new, longer stoma. Unfortunately, adhesions, an unmobilized splenic flex-
ure, and a foreshortened mesentery can conspire to prevent adequate local
mobilization, thus necessitating laparotomy.
Urostomies are associated with special problems requiring both sys-
temic and local solutions. Urine normally contains no proteolytic enzymes
and is slightly acidic. Therefore skin damage from urine is caused by pool-
ing of the urine on the peristomal skin, which results in maceration. Alka-
line urine, however, when in prolonged contact with the skin, causes en-
crustations—around the mucocutaneous junction, on the stoma itself, or
inside the bag—consisting of triple phosphate (calcium, magnesium, and
ammonium phosphate) or uric acid crystals [6,7]. Such crystals formation
can cause small lacerations at the mucocutaneous margin [7]. The treatment
is simply a combination of increased fluid intake and acidification of the
urine with vitamin C (up to 8 g/day) and the administration of cranberry
juice or cranberry pills. The crystals themselves can be gently removed
using washes or compresses or half-strength vinegar until they are gone
[7,8].
Allergic Contact Dermatitis
Allergic contact dermatitis results from a reaction to a specific allergen in
an ostomy product [9]. Severe contact dermatitis may occur from the adhe-
sive material on one-piece appliances or from the adhesive tape, powders,
pastes, clamps, and belts. An allergic dermatitis can usually be confirmed
whenever an area of inflammation corresponds to the area covered by a
particular product. Allergy is manifest by cutaneous erythema and blister
formation with severe pruritus or burning (Fig. 3). The condition can be
treated with topical corticosteroid sprays and oral antihistamines for relief
of itching. Systemic steroids may be indicated for severe reactions [6,7].
Patients with pre-existing and established allergies to food, medications, or
other topical agents should be skin tested for possible sensitivity to ostomy
products prior to surgery [3].
Trauma (Mechanical Irritation)
Denuded, inflamed skin may result from abrasive cleansing techniques,
friction, and pressure from ill-fitting equipment, belts that are too tight, or
Peristomal Skin Conditions 385
Figure 3 Allergic reaction to the adhesive used with an ostomy device.
poorly fitted wafers. Skin breakdown and epidermal stripping may also oc-
cur from excessive rubbing to remove old paste or from traumatic tape
removal. The affected skin is painful, and the moist, bleeding areas under-
mine the pouch seal, resulting in frequent pouch changes and exacerbation
of the problem [3]. Factors that contribute to mechanical trauma include
weight gain, weight loss, peristomal hernia, and prolapse. When such trauma
occurs, reassessment of the patient’s pouch removal technique, skin care,
and length-of-wear time is warranted. Appliance wear time should be at
least 4 and preferably 5–7 days. Re-education—including correction of im-
proper technique—is essential. Denuded areas may require skin barrier
powders and alcohol-free skin barrier wipes to create an effective adhesive
seal [9].
Folliculitis
Inflammation within the hair follicle is caused by trauma due to careless
appliance removal, too frequent or too close shaving of peristomal hair
with a blade-type razor, or excessive rubbing or cleansing. Erythematous,
pinpoint, pustular lesions appear at the bases of the hair follicles around the
stoma. These lesions may suggest yeast infection, but they are usually
caused by Staphylococcus aureus. Antibacterial powders can be prescribed.
The problem is best prevented by cutting the peristomal hair with scissors
or using an electric razor. Depilatory agents are seldom recommended be-
cause of the high incidence of allergic reaction to these products [3].
386 Mahmoud and Bradley
DERMATOSES
Pyoderma Gangrenosum
Pyoderma gangrenosum (PG) is a debilitating, idiopathic dermal manifesta-
tion of underlying chronic disease. Although it is most commonly described
as affecting those with inflammatory bowel disease, it can be seen in pa-
tients with polyarteritis nodosa, hepatitis, rheumatoid arthritis, and underly-
ing malignancies [10]. Peristomal PG can occur in Crohn’s disease as well
as ulcerative colitis, occurring in 2% of cases treated by stoma [11]. Be-
cause it is so uncommon, it may go unrecognized and therefore underre-
ported. On physical examination, the lesions are characterized by small pus-
tules that enlarge and break down, forming burrowing, deep-seated pyogenic
ulcers with necrotic centers and serpiginous borders (Fig. 4). The rapidity
of its development and spread is considered a hallmark of the lesion [10,
12]. Histologically, biopsies of the lesions are quite nonspecific, showing
only evidence of acute and chronic inflammation with no granulomas or
fungus [11].
In a number of small case series and reviews, patients suffering from
peristomal PG are slightly more likely to be females suffering from Crohn’s
disease. A number of these cases have occurred in the presence of active
disease—especially active proctitis [10]. Diagnosis of PG is facilitated by
prompt recognition of the rapidly spreading peristomal serpiginous lesions
Figure 4 Peristomal pyoderma gangrenosum. (From Ref. 10.)
Peristomal Skin Conditions 387
in patients with irritable bowel disease (IBD) and by maintaining a high
index of suspicion. Treatment of the lesions can be difficult. As with all peri-
stomal dermatoses, ulcers cause difficult pouching problems. Most regi-
mens include good local wound care. Ulcer irrigation, dressing of the
wound with gauze, isolating the ulcer from effluent, and use of hydrocorti-
sone creams have been described [10,12]. Others promote the use of hydro-
gels, calcium alginate, and hydrocolloid in the topical care of the ulcers. If
the ulcers cover an area greater than one-third the circumference of the
peristomal region, a nonadherent pouching system of belts and gaskets can
aid healing by reducing irritation, trauma, and pressure [13]. The corner-
stone of treatment, however, seems to be intravenous and oral steroids.
Initial high-dose therapy (20–100 mg/dL) is quickly tapered to an oral
dose, on which the patient is maintained until the ulcers are well on their
way toward healing. Intralesional injection of steroids, particularly triamci-
nalone acetonide (30 mg/mL), is reported to speed healing and is suggested
as an initial measure [14]. Even with rigorous wound care and systemic
therapy, most surgeons report slow wound healing times ranging from 6
weeks to 6 months [11]. It has been recognized anecdotally that persistent
ulcers may heal promptly when, with treatment, the underlying disease be-
comes quiescent, particularly in the case of Crohn’s proctitis. Completion
proctectomy and resection of persistently inflamed bowel is noted to cause
prompt regression of peristomal disease; however, local surgical interven-
tions, including ulcer excision and stoma revision, seem to worsen the prob-
lem and may cause exacerbation of PG at distant sites. They are therefore
are contraindicated [15,16].
Bullous Pemphigoid
Bullous pemphigoid is a well-recognized skin condition rarely reported at
colostomy or ileostomy sites. It is characterized by tense blisters of varying
size on either normal or reddened skin. The blisters occur on both mucosal
and keratinized skin, typically with extensive body surface involvement in
the elderly [17]. Histological examination of the involved tissue reveals
separation at the dermoepidermal junction, the presence of an intact epider-
mis, an underlying subepidermal bulla, and a large number of eosinophils
[18]. Direct immunoflorescence demonstrates IgG and C3 at the level of
the epidermal basement membrane (dermoepidermal junction) [17–19]. Pa-
tients are often initially misdiagnosed with a contact dermatitis, folliculitis,
or even peristomal abscesses. Biopsy and histopathological examination are
necessary to make the diagnosis. Clinically, the lesions, when ruptured,
contain clear, not purulent, fluid. They tend to recur and do not respond
well to local therapy alone. Localized bullous pemphigoid (LBP) may occur
in areas of trauma (Ko
¨
bner phenomenon), although this association is
somewhat speculative.