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398 Casey et al.
current concepts suggest a primary immunological mechanism [8], it is un-
clear whether this is directed specifically at the skin or is part of a more
generalized autoimmune response to the underlying systemic disease.
Clinically, the lesion begins as a number of pustules that erupt and
quickly coalesce into the classic painful ulcer with a violaceous border and
undermined edge (Fig. 1). Most often, the lesion affects the pretibial region
of the lower extremities. Multiple lesions are the rule rather than the excep-
tion [7,10,11]. An associated history of trauma to the affected area preced-
ing the development of pyoderma has been reported in 10–27% of patients
[7,10,11]. Pyoderma gangrenosum has also been described in association
with surgical incisions [12].
Parallel activity of the intestinal aspect of the inflammatory bowel dis-
ease in pyoderma gangrenosum continues to be a source of debate, as is the
response of the skin lesions to medical and surgical therapy of the underly-
ing ulcerative colitis or Crohn’s disease [4,6,7,11]. Most physicians agree
that the clinical course of pyoderma often correlates with the degree of intesti-
nal inflammation; however, pyoderma is also seen in patients with inactive
bowel disease and has been noted after surgical extirpation of ulcerative
colitis. When pyoderma gangrenosum develops in a patient with clinically
Figure 1 Typical pyoderma lesion with a deep punched-out ulceration, under-
mined edges, and violaceous border.
Unusual Problems in Stoma Management 399
inactive Crohn’s disease, the intestinal tract should be reevaluated for evi-
dence of recrudescence of intestinal disease activity. Successful medical ther-
apy of the inflammatory bowel disease has been associated with the healing
of pyoderma in approximately two-thirds of patients [11]. Bowel resection
has been suggested for patients with refractory pyoderma; however, when
all of the disease is removed, healing of the skin lesions is seen in less than
half of patients without additional treatment of the pyoderma itself. In pa-
tients with mild ulcerative colitis, prolonged delays in healing of the skin
lesions may occur; whereas in patients with severe inflammatory bowel
disease, the cutaneous lesions tend to heal promptly with medical treatment
[6]. Persistence or recurrence of pyoderma may be related to an operative
procedure that leaves residual diseased bowel, such as subtotal colectomy
for ulcerative colitis or a bypass procedure for Crohn’s disease [7]. Because
healing cannot be guaranteed after resection and pyoderma may appear de
novo in the postoperative period after removal of the diseased bowel, the
surgeon should be cautious in recommending operation solely on the basis
of the presence of refractory pyoderma gangrenosum.
Surgery for inflammatory bowel disease often results in the creation
of an ileostomy. Margoles and Wenger [13] were the first to report an associa-
tion between peristomal pyoderma and ulcerative colitis. McGarity and as-
sociates [14] established the association between peristomal pyoderma and
Crohn’s disease. Last and colleagues in 1984 [15], in a discussion of para-
stomal ulcers and Crohn’s disease, presented a differential diagnosis of
these lesions, including infected hematomas, stitch abscesses, fistulas, and
reactivation of Crohn’s disease. Parastomal pyoderma gangrenosum was
not mentioned as a separate entity. A later series [16] reported that half of
refractory parastomal ulcers were pyoderma gangrenosum.
Clinical presentation of peristomal pyoderma may be confusing. Fis-
tula and abscess at the suture line may be indistinguishable from the early
pustules of pyoderma, with a prodrome of pain, erythema, and tenderness.
When the typical ulcer has formed, the diagnosis becomes more apparent
(Fig. 2).
Particular problems with parastomal pyoderma are pain under the ap-
pliance and an inability to maintain a seal between the appliance and the skin.
The goals of therapy must be to address local management of the ulcer
and the underlying illness predisposing to the complication. In most series,
debridement is rarely successful and increases the size of the peristomal
ulceration that must be dealt with [17]. Local wound care of the ulcer is a
necessity in managing these patients. When the ulcer is small, with minimal
exudate, the granulating base is covered with Telfa (Kendall Company,
Boston, MA), and the existing pouching system is replaced. A composite
foam can be used to contain a moderate amount of exudate; this foam pro-
vides for a painless removal of the flange and less trauma to the wound
bed. Daily changes are required to remove the exudates and prevent under-
400 Casey et al.
Figure 2 Parastomal pyoderma gangrenosum bordering an iloeostomy.
mining of the adhesive wafer [15]. Other forms of local treatment include
Domeboro compresses (Miles Pharmaceutical, West Haven, CT), topical
antibiotic ointments, and corticosteroid creams [18]. Although topical prep-
arations are not typically recommended because they interfere with pouch
adherence, the above measures do play an important role in the treatment
of pyoderma.
When the ulcer is large, with considerable wound seepage, hydro-
active materials may be used to promote healing in a moist environment.
Acquacel (Convatec, Princeton, NJ), a hydrofiber wound dressing, is soft,
absorbable, and comfortable [17]. This dressing, when interacting with
wound exudates, forms a soft gel that maintains a moist environment while
facilitating removal of the pouching system [19]. Due to the high volume
of moisture, a Duoderm wafer over the Acquacel is used to achieve a seal
of the appliance. Methods of moist wound healing combined with topical
steroids have been used with some success [18].
When the disease is severe, the ulcer surrounds the stoma and leaves
no usable skin surface for the pouch. Under these circumstances, the Perry
model 51 pouch (Perry Products, Minneapolis, MN) may be beneficial. It
is a nonadhesive collection device that may be changed frequently to permit
daily wound care [15]. Protrusion of the stoma is a prerequisite for success
of this system; when the stoma is flush or retracted or when local manage-
Unusual Problems in Stoma Management 401
ment of the ulcer is not successful, relocation of the stoma must be consid-
ered.
Topical application of disodium cromoglycate, an antiallergy medi-
cation that stabilizes mast cells and thus hinders histamine release, has been
used to treat pyoderma gangrenosum in association with inflammatory bowel
disease [20,21]. Although the mechanism of action is unknown, speculation
based on the drug’s action on mast cell function suggests that the drug re-
duces the inflammatory response, leading to healing. In conjunction with
the department of dermatology at the Lahey Clinic, a protocol of Domeboro
compresses to the ulcer and twice-daily application of both disodium cro-
moglycate and topical steroid cream to the edge of the ulcer has been devel-
oped. The lesion is then covered with Telfa to help provide a dry environ-
ment. This protocol has resulted in the most consistent healing of parastomal
pyoderma gangrenosum.
Intralesional injection of steroids was first successfully reported by
Moschella [22]. Other authors [23] have reported success with injections
of triamcinolone around the periphery of the lesions, usually in combination
with systemic or topical corticosteroids. The Lahey Clinic experience with
this regimen has resulted in a satisfactory response in approximately 50%
of patients [4]. Many patients with pyoderma gangrenosum are already be-
ing treated with steroids for inflammatory bowel disease. Increasing the
dose may result in dramatic improvement of the pyoderma. Whether this is
a primary effect on the skin is speculative.
Newer systemic therapies include the use of cyclosporine, which can
be administered intravenously [24], orally [25], or both. Reports indicate a
very high healing rate with the use of this drug, with considerable improve-
ment in some patients with active intestinal disease as well. Immunosup-
pression can also be accomplished with FK506 (tacrolimus), which may be
used topically or systemically [26]. This drug has been reported to have
utility even in patients with failure of cyclosporine, with the added advan-
tage that it can be applied topically with persistent beneficial effects.
Peristomal pyoderma gangrenosum requires prompt and aggressive
management of the parastomal ulcers as well as the underlying inflamma-
tory bowel disease. Failure to control either may mandate surgical interven-
tion. Resection of all actively inflamed bowel may permit healing of the
pyoderma. Management often requires close cooperation among surgeons,
gastroenterologists, dermatologists, and enterostomal therapists to resolve
this unusual but debilitating complication.
PARASTOMAL VARICES
Creation of a stoma in a patient with underlying liver disease may be com-
plicated by the development of parastomal portal systemic venous shunts.
Presumably these shunts are a result of anastomoses between mesenteric
402 Casey et al.
veins and systemic subcutaneous veins. Paracolostomy varices were first
reported by Resnick and colleagues [27], who noted that coincident esopha-
geal varices did not bleed in patients with this parastomal collateral path-
way. Paraileostomy varices were first noted by Eade and colleagues [28] in
patients undergoing proctocolectomy for inflammatory bowel disease.
These authors applied the term caput medusae to the characteristic appear-
ance of dilated veins around the stoma (Fig. 3). Varices have also been
described [29] around ileal conduits created for treatment of various urolog-
ical conditions. The sole symptom of this rare condition is hemorrhage,
which may be life-threatening.
In a review of all reported cases from 1962–1989, Conte and associ-
ates [30] analyzed 72 cases, of which 49 involved bleeding from an ileos-
tomy, 15 from a colostomy, and 8 from an ileal conduit. Ulcerative colitis
was the most common reason for ileostomy, whereas carcinoma of the rec-
tum or bladder was the most frequent reason for colostomy or ileal conduit.
Primary sclerosing cholangitis was the most frequent underlying liver dis-
ease in patients with an ileostomy. In a series of 72 patients undergoing
surgery for ulcerative colitis with sclerosing cholangitis, parastomal varices
occurred in 25% of patients undergoing proctocolectomy and none of 40%
of patients undergoing ileal pouch anal anastomosis [31]. This observation
Figure 3 Caput medusae surrounding an ileostomy.
Unusual Problems in Stoma Management 403
must be considered in evaluating patients for surgery. Metastatic liver dis-
ease was the most frequent cause of parastomal varices in patients with a
colostomy. Alcoholic cirrhosis was the most common predisposing liver
condition. The interval between creation of the stoma and the subsequent
development of varices varied between 2 and 348 months. The clinical pre-
sentation in nearly all patients was recurrent episodes of painless gastroin-
testinal tract bleeding.
Early experience with the management of parastomal variceal hemor-
rhage indicated that local pressure, sometimes with the addition of topical
hemostatic agents, should be the initial procedure of choice [32]. Correction
of circulating blood volume and clotting abnormalities should be accom-
plished as expeditiously as possible. When local pressure is insufficient,
suture ligatures may be placed peripheral to the mucocutaneous junction.
Mucocutaneous disconnection, in which the stoma is circumferentially de-
tached from the skin and subcutaneous tissue to the level of the fascia with
ligation of the varices, has also been successful [32–34]. When these mea-
sures are unsuccessful, relocation of the stoma may be necessary.
Because of the success of sclerotherapy in the treatment of patients
with esophageal varices, sclerosing solutions have been injected into para-
stomal varices [35,36]. The technique involves injection of a sclerosant into
the tissues peripheral to the mucocutaneous junction rather than injection
directly into a discrete varix, which is usually not identifiable. Sclerother-
apy can be repeated as necessary in an attempt to obliterate the varices and
to lengthen the intervals between bleeding episodes.
These local procedures must be implemented with careful attention to
the details of the stoma pouching procedures. Bleeding at the site of the
stoma can be aggravated by a pouching system that is too small for the stoma.
The enterostomal therapist must teach the patient how to measure the stoma,
using the guides provided by the manufacturers of ostomy equipment. A
one-piece appliance cut
1
⁄
8
–
1
⁄
4
in. larger than the stoma should be recom-
mended. Stomahesive paste (Convatec Inc., Princeton, NJ) can be used to
protect visible skin when the appliance is cut larger than the stoma [37].
After the proper size of the equipment is determined, the patient must dis-
continue the use of ostomy belts and rigid face plates. These products can
cause friction, local trauma, and erosion at the mucocutaneous junction,
which may aggravate bleeding. Patients must also be instructed in the
proper gentle removal of the appliance to minimize trauma. Optimal integ-
rity of the parastomal skin must be maintained to avoid further episodes of
bleeding and protect against further injury. The patient must also be in-
structed regarding methods of digital local control for emergency situations.
These local measures are designed to reduce the frequency of bleeding
episodes. In the review by Conte and associates [30], digital pressure alone
was accompanied by rebleeding in 98% of patients within 10 months. Su-
ture ligature, mucocutaneous disconnection, and revision of the stoma were
404 Casey et al.
accompanied by a rebleeding rate of 100%, necessitating further surgery in
many patients. Sclerotherapy yielded similar results.
Controversy regarding the role of portosystemic shunting has existed
since the original description of this approach in 1970 [38]. A central sple-
norenal shunt was reportedly [39] successful in three patients with para-
ileostomy varices, as evidenced by no recurrent bleeding and no hepatic
encephalopathy. In the collected series [30] of 72 patients, 27 were treated
by portosystemic shunting. Most patients had had multiple procedures be-
fore portal decompression was attempted. A central splenorenal shunt was
commonly used, followed by an end-to-side portocaval shunt. A distal
splenorenal shunt was successful in controlling bleeding in two of three
patients in the Lahey Clinic series [34]. Rebleeding was seen infrequently
after portosystemic shunt procedures, with an acceptable operative mortal-
ity rate and absence of encephalopathy. Before a shunt is considered, all
patients should be evaluated with biochemical testing, mesenteric angiog-
raphy, and liver biopsy when appropriate.
Transjugular intrahepatic portosystemic shunt (TIPS) is an angio-
graphic technique in which an expandable metal stent is introduced via the
hepatic vein through the hepatic parenchyma into the portal venous system.
This innovative procedure avoids abdominal surgery in patients who are
frequently systemically ill while preserving the portal anatomy for subse-
quent surgery. It has been successfully applied to patients with parastomal
varices [40,41] and should be considered as a viable and perhaps preferred
alternative to portosystemic shunt by laparotomy.
Despite the potential severity of recurrent bleeding from parastomal
varices, few patients die as a direct result of this complication. Rather, life
expectancy is determined by the nature and severity of the underlying liver
disease. Consequently, treatment planning must be based on long-term sta-
tus and function of the liver, including the possibility of hepatic transplanta-
tion. When portal hypertension is the result of metastatic liver disease or
when severe benign liver disease precludes safe performance of portosys-
temic shunting or liver transplantation, local measures must suffice. If, on
the other hand, the patient is a potential candidate for transplantation, local
measures should be used to temporize the problem until deterioration of
liver function justifies liver transplant. If local measures are unsuccessful,
a distal splenorenal shunt or some other peripheral shunt is preferred to
a central shunt, which may render transplantation technically difficult or
impossible.
ADENOCARCINOMA IN AN ILEOSTOMY
Adenocarcinoma arising in an ileostomy is still rare enough to be described
in isolated case reports. Since the original description in 1969 [42] through
Unusual Problems in Stoma Management 405
1993, a total of 16 cases had been reported [43–52]. An additional case of
adenocarcinoma arising in an ileostomy was thought to be secondary to
residual rectal carcinoma after resection of an ileorectal anastomosis with
creation of an ileostomy [53].
The majority of reported cases of adenocarcinoma arose in an ileos-
tomy originally performed for chronic ulcerative colitis, although in ap-
proximately one-third of patients the primary diagnosis was familial ade-
nomatous polyposis. Delay between construction of the iloeostomy and
subsequent carcinoma in the iloeostomy varied between 9 years and 38
years, with a median of 23 years. Presenting symptoms included bleeding,
parastomal ulceration, and a change in the appearance of the stoma. Pain
and obstruction have also been observed, although less frequently.
Pathologically, the tumor is usually a well-differentiated or moder-
ately well-differentiated mucin-producing small bowel adenocarcinoma
arising at the mucocutaneous junction. Variable amounts of invasion of the
skin and subcutaneous tissue have been described. In only one patient was
mesenteric adenopathy reported to be present [51]. Of potential importance
is the description of ileal mucosal dysplasia associated with carcinoma in
five patients [43,45–47,50].
The clinical presentation of paraileostomy carcinoma should suggest
the diagnosis. Inspection of the parastomal skin reveals an ulcerated mass
(Fig. 4); a biopsy should be obtained under local anesthesia. Sampling error
may result in diagnostic inaccuracy. Consequently, when the clinical suspi-
cion is strong, further biopsies should be obtained; this may require general
or regional anesthesia. Definitive surgical management is excision of the
iloeostomy and the distal small bowel with a wide margin of the abdominal
wall resected in continuity. The stoma should be translocated to an alterna-
tive site, with closure of the primary abdominal wall defect. No reported
cases have required major tissue transfer, although prosthetic mesh may be
necessary for abdominal wall reconstruction [51]. In two reports [42,47],
metastatic disease to the liver was the cause of death in two patients. Recur-
rence of disease in the abdominal wall is a consideration, but adjuvant ra-
diotherapy has not been advocated. In one report [49], a recurrent pelvic
adenocarcinoma was managed successfully by radical resection. Follow-up
data are not sufficient to indicate a definitive prognosis in these patients.
Speculation regarding the cause of paraileostomy carcinoma is based
on the association of backwash ileitis and dysplasia noted in many of these
patients. One report [54] suggested an association between backwash ileitis
and subsequent ileal dysplasia and ileal carcinoma. If this were true, one
might undertake a routine prospective surveillance program with ileoscopy
and biopsy in all patients having undergone construction of an ileostomy
for either ulcerative colitis or familial polyposis. The rarity of this clinical
entity, however, may not justify such an aggressive approach. Rather, regu-
406 Casey et al.
Figure 4 Invasive adenocarcinoma arising in an iloeostomy.
lar inspection of the stoma by a physician or enterostomal therapist with
selected biopsy of abnormal areas is probably sufficient.
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