Grand Rapids Ostomy Association
Helping People with Ostomies and Alternate Surgeries in Southwest Michigan
Types of Colostomies
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The material presented here is a compilation of the experiences of many hundreds of patients, and/or devoted nurses and physicians. We talked and corresponded with them and read their writings. We are deeply grateful to them for sharing what they know so that others might benefit.
The United Ostomy Association, Inc., wishes to express its gratitude to the following
people for their outstanding contributions in revising this booklet:
James W. Fleshman, MD
Member, Medical Advisory Committee
United Ostomy Association, Inc. (UOA)
Susan Currence, RN, CETN Chair, Consumer Education Committee International Association for Enterostomal Therapy (IAET)
Bernie Cullen, RN, CETN Member, Consumer Education Committee IAET
Joan Doyle, RN, BSN, ET Member, Consumer Education Committee IAET
Melinda Petillo, RN, MSN. CETN Member, Consumer Education Committee IAET
Sheri Smith, RN, MSN. CETN Member, Consumer Education Committee IAET
Gretchen Thompson, RN. BSN, CETN Member, Consumer Education Committee IAET
Marilyn Mau, President, United Ostomy Association, Inc. (UOA)
Linda King Aukett, Director, Regional Program, UOA
TennieBee Hall Past President, UOA and Editor Ostomy Quarterly
Jeanne Colberg, RN, ET Director, UOA
Helen DuBois, RN, ETDirector and Member, Publications Committee UOA
Mike Schreiber,Member, UOA, Dallas, Texas
April Gimlen,Chair, Parents of Ostomy Children Taskforce UOA
Cy Smith,Revision Coordinator, Director and Chair, Publications Committee, UOA
Colostomy surgery is performed for many different diseases and conditions. Some colostomies are done because of malignancy(cancer), others are not. In children, they may be created because of birth defects. Sometimes a colostomy is temporary, sometimes it is permanent. Some colostomies appear large, some small; some are on the left side of the abdomen, some are on the right side, others may be in the middle.
Think of your colostomy’s function as you did of your natural bowel evacuation. You still have the same bowel, just a little less of it. The real change is having a bowel movement from an opening made in the abdomen. You will be able to adjust to it as you learn the necessary techniques.
There is no one way to take care of a colostomy. As colostomies differ, so does taking care of them. This article offers you suggestions and ideas for managing your colostomy. Use it as a guide rather than a textbook. Discuss the ideas with a physician or enterostomal therapy nurse (ET nurse) and adapt them to your situation. Give new things a fair trial but do not continue them if they fail to make you more comfortable. What is good for someone else may not necessarily be good for you. The sooner you learn to care for your colostomy, the better. Use the weeks of recovery for learning and trying different things.
In our society, bathroom needs are kept private. This is the same for a person with a colostomy. While you learn the new procedures, you may need help. Before long, however, you will again be in control. A good sense of humor and common sense are vital ingredients when changes in body function occur. Be confident, you can learn the new system.
There are many ways you can gain a greater understanding of your future life with a colostomy. This booklet will give you helpful facts about living with it; your physician, ET nurse or other nurses are important sources of information and support. A special source of help with your adjustment is an ostomy visitor. The visitor is a person who, like you, has had colostomy surgery. He or she can answer many of your questions about day-to-day life. Your ostomy visitor has successfully adapted to the changes which ostomy surgery makes, and can help you see how you can adjust too.*
You may also be helped by taking part in an ostomy support group. A support group allows you to share your feelings and ask questions as you make progress with your adjustment. It also allows you to share your successful adjustment with others who may need the benefit of your own experience.* Most ostomy visitor programs and support groups are sponsored by local chapters of the United Ostomy Association (UOA). If you would like to see a visitor or take part in a support group, ask your physician, El nurse, or other nurses. You or your family may also locate the local UOA chapter by checking your telephone directory or by asking local health-related referral services.
Some diseases of the colon are treated by creating an exit for thefeces feces before they reach the rectum. A colostomy is such a procedure. (The word colostomy is from the words colon and stoma, stoma meaning mouth or opening).
When certain conditions are present in the lower bowel, it may be necessary to give that portion a rest. This is done by preventing feces from reaching it. To do this, arectum become diseased, construction of a permanent colostomy becomes necessary. That portion must be totally removed or permanently rested. Such a colostomy provides a fixed exit for feces and will not be closed at any time in the future.
Where on the abdomen the colostomy will be located depends on which part of the colon is used to make it. The ET nurse or the surgeon will determine the correct location for your stoma.
The appearance of the stoma depends on the type of colostomy the surgeon makes and on individual differences in the human body. While the stoma may be quite large at first, it will shrink gradually and attain its final size in six to eight weeks.
When you look at a stoma, you are actually looking at the lining (the mucosa) of the intestine. Similar to the lining of the cheek, it is warm and moist and secretes small quantities of mucus. Unlike the anus, the stoma has no valve or shut-off muscle. For this reason, willful control of the passage of stool is not possible. Management of bowel movements is discussed in the chapter Methods of Colostomy Care (page 16).
Although a colostomy creates an important change for the patient, it is surgically a rather simple operation. The body’s chemistry and digestive function are not altered by it. *
In order to appreciate how the body can function with a colostomy, let us review the normal function of the intestinal tract.
After food is chewed and swallowed, it passes through the esophagus into the stomach and from there, it enters the small intestine. Several hours go by before it appears in the large intestine (colon). Finally, after hours or even days, it leaves the body by way of the anus. Throughout most of its passage, the food is liquid and loose. Absorption of water takes place in the colon and this causes the fecal material to become a firm mass as it nears the rectum.
The small intestine (ileum) is the longest section of the tract. This is where food is digested and absorbed. It begins below the stomach as the duodenum. The second portion is the jejunum and the last, the ileum. It lies loosely curled in the abdominal cavity.
The large intestine (colon) joins the small intestine where the ileum and cecum meet on the body’s right side. From there, it extends upward as the ascending colon. It turns left and crosses to the other side of the body as the transverse colon. Again it turns and now descends on the left side as the descending colon. An S-shaped portion, the sigmoid, leads to the rectum in the center of the pelvis. The rectum is eight to ten inches long and ends in the anus.
The colon’s work consists primarily of extracting water from the fecal mass, transportation, and storage. There are two major types of activities in the colon, peristalsis and mass reflex. During peristalsis, the muscles of the colon are constantly contracting and relaxing. These movements occur throughout the different parts of the colon, but are not noticed. The purpose of peristalsis is to mix and knead the food and to extract water, thus forming the
end product, feces. When feces collect in a portion of the colon, muscles in that part relax and stretch to accommodate them. Pressure builds as the limit of stretch approaches. At this point, a mass reflex, stronger than peristalsis, propels the feces into the next portion of the colon. From there, it moves into the rectum. This occurs automatically, several times a day, and usually follows a meal or a drink
The two end portions of the intestinal tract are the rectum and anus. Special nerve pathways to the brain make us aware when the fecal mass reaches this section. Only then is the digestive process subject to our will. As the fecal mass enters the rectum, we feel the desire to have a bowel movement. The anal sphincter allows us to control this desire. Unlike the rest of the intestinal tract, it contracts or relaxes at our will. Contraction will stop a bowel movement while relaxation will permit it to continue.
After a colostomy has been created, the intestines will function as the intact intestine did except:
• The colon beyond the colostomy (and/or the rectum) is disconnected or removed.
• The anus no longer serves as the exit.
Since nutrients are absorbed in the small intestine, a colostomy does not affect the body’s ability to be nourished. As stated above, the main functions of the colon are to absorb water, to transport the feces toward the anus and to store it in the rectum until evacuation becomes necessary. When a colostomy interrupts the passage of feces, storage becomes less easily possible. The higher up in the colon the colostomy is made, the less time the bowel has to absorb water and the more liquid (or soft) the stool is likely to be. Therefore, a colostomy in the transverse colon will discharge a softer and more voluminous stool and will require the use of a colostomy appliance.
A colostomy far down in the colon, near the rectum, will discharge feces that has been in the intestine a longer time and barring the effects of illness or medications, or other forms of treatment, may produce a more formed stool. Some colostomates find that they are able to pass this stool at regulated times with or without the help of an irrigation.
After the operation, patients may feel urges and even have some discharge from the anal area. This discharge is mucus, blood, and at times feces, remaining from the time of the operation. If the rectum is intact, it will continue to secrete mucus which can be harmlessly passed whenever the urge occurs.
A colostomy can be temporary or permanent and can be made
in any portion of the colon.
The loop colostomy may appear like one very large stoma. However, it actually has two openings. One opening discharges feces, the other expels only mucus. A colon normally makes small amounts of mucus to protect itself from the bowel contents. The mucus passes with the bowel movements and is usually not noticed. Despite the colostomy, the resting part of the colon continues to make mucus which will come out either through the stoma or through the rectum and anus; this is normal and expected.
When making a double-barrel colostomy, the surgeon divides the bowel completely. Each opening is brought to the surface as a separate stoma; they may or may not be separated by skin. Here, too, the one opening discharges feces and the other discharges mucus (this stoma is referred to as a “mucous fistula”). Occasionally, the mucus fistula is sewn closed at the time of surgery and left inside the abdomen. In such a case, only one stoma would be visible on the abdomen (single-barrel colostomy). Mucus from the resting portion of the bowel would pass out through the rectum.
You will soon notice that, although you can usually tell when your colostomy is going to pass feces or gas, you cannot control the movement. Your colostomy does not have a sphincter or control mechanism as your anus does. For this reason, you will wear a pouch over your colostomy to collect the output. Your ET nurse or physician will help you select a pouching system that is right for you.
When a colostomy is located in the right half of the colon, only the short portion of colon leading to it is active. The consistency of the discharge from a transverse colostomy varies from person to person and from time to time within one individual. A few transverse colostomies discharge a firm movement at infrequent intervals, but most of them move fairly often with a soft or loose stool. The feces contain some digestive enzymes which are quite irritating to the skin.
Attempts to control a transverse colostomy with special restrictive diets, medications, enemas, or irrigations are generally unsuccessful and therefore are rarely recommended. Usually, an appliance is worn over a transverse colostomy at all times. A lightweight, inconspicuous, drainable appliance holds the colostomy output and protects the skin from contact with the feces.
Deciding what is best for you is a very individual and personal matter. However, in selecting your appliance, it is best to consult someone who knows how to fit ostomates. Among these, first and foremost, are the El nurses. Many physicians and nurses have experience in this area as well. Hopefully, there will be someone in the hospital who is experienced and will get you started with equipment and instruction. Once you have left the hospital, be sure you have a referral to a knowledgeable El nurse, a clinic, or a United Ostomy Association Chapter. Even if you must go out of town to get such help, it is worthwhile, as you want to get a proper start and avoid making mistakes. (See section “Where to Find Help.”) In addition to appliances, you may need a number of items to attach and remove them, to make them fit well, to protect the skin and to eliminate the likelihood of embarrassing odors.
When the colostomy is made, there may or may not be a plan to close it again. Not all transverse colostomies can or should be closed.
If you are a candidate for closure, the surgeon may say that he plans to take it down” in a few weeks or months; then, again, he may not say anything. His plan and subsequent decisions are subject to many considerations: the original reason for the colostomy, the ability of your body to tolerate surgery, your health since the operation, problems which may have happened during or after surgery, to name a few.
It is wise to discuss these matters with your surgeon before you leave the hospital so that you know what his plans are and when he wants to examine you. If you are home now and received no instructions, call the doctor’s office or clinic and find out what the doctor wants you to do. The responsibility for staying in touch with the doctor is yours.
The ascending colostomy is located on the right side of the abdomen. The discharge is very liquid. A drainable pouch is worn for colostomies of this type. This type of stoma is rarely used since an ileostomy is a better stoma when the discharge is liquid. When a colostomy is located in the right half of the colon, only a short portion of colon remains. Feces in the right half of the colon are liquid and contain many digestive enzymes. The discharge from an ascending colostomy will usually be loose or semi-solid. It can also he irritating to the skin due to the action of the enzymes. Since elimination is more or less continuous and unpredictable, regularity is impossible with such a colostomy. It is necessary to cover the colostomy with a lightweight, drainable pouch. This will protect the skin from contact with the stool. Caring for an ascending colostomy is similar to caring for a transverse colostomy.
Located at the end of the descending colon, the descending colostomy is located on the lower left side of the abdomen. Generally, the discharge is firm and can be regulated. A sigmoid colostomy, differing from a descending colostomy, is in the sigmoid colon, just a few inches lower in the intestinal tract. Because of this, it may produce more solid and more regular fecal discharges. The sigmoid colostomy is probably the most frequently performed of all the colostomies. Both the descending and the sigmoid colostomies can have a double-barrel or single-barrel opening. The single-barrel, or end colostomy, is the more common type. The stoma of the end colostomy is either sewn flush with the skin or it is turned back on itself (like the turned down top of a sock)
The stool of a descending or sigmoid colostomy is firmer than that of the transverse colostomy and without the caustic enzyme content. At this location, elimination may occur on a reflex basis at regular, predictable intervals. The bowel movement will take place after a considerable quantity of stool has collected in the bowel above the colostomy. Two or three days may elapse between such eliminations. Spilling may happen between movements because there is no anus to hold the stool back. Many people use a lightweight, disposable pouch to prevent acddental soiling. A reflex will set up quite naturally in some people. In others, mild stimulation, such as juice, coffee, a meal, a mild laxative, or an irrigation is necessary.
While many descending and sigmoid colostomies can be trained to move regularly, others cannot. You must realize that satisfactory training, with or without stimulation, is likely to happen only in those people who have had regular bowel movements before they became ill. If the bowel has been irregular and temperamental in earlier years, it may be quite difficult, or impossible, to have regular, predictable colostomy function. Spastic colon, irritable bowel, and some types of indigestion are conditions in which the patient has bouts of constipation or loose stool. A person who has had such a condition in the past, before he became ill, may not achieve regularity any better with a colostomy, than without one. It is often said a person must have a bowel movement every day. Actually, people vary greatly in this respect. Some have two or three movements a day, others have one every two or three days or even less often. You must judge constipation and loose bowels by what is usual for you, not what is usual for others.
Care of any colostomy is really not very difficult in the long run, but getting to that point involves a lot of learning, a lot of practice, the right materials and a positive attitude. Keep in mind the following points:
It is possible to treat the bowel movement through a colostomy like a normal movement through the anus, just let it happen naturally. However, unlike the anal opening, the colostomy does not have a sphincter which can stop the passage of a movement. As a result, a pouch must be worn to collect anything which might come through, whether it is expected or not. A large variety of these lightweight, inconspicuous pouches are available. They adhere to the abdomen around the colostomy and may be worn at all times, or worn only as needed.
Over the years, colostomy pouches have improved greatly. Those available years ago were bulky and became malodorous. Today, there is a wide selection of pouches that do not even show under clothing. Since they are made of disposable materials, they are worn once, or just a few times, and then discarded.
You may not need to wear a pouch; if not, that’s fine. On the other hand, it is not a sign of failure if you need to wear one occasionally or even all the time. Many colostomates wear a pouch, for example, those who have a transverse colostomy, those who do not wish to irrigate, and those who have some return between irrigations.
Pouches come in a variety of styles and sizes. Basically, they all do the same job. They collect fecal drainage which may come through, expectedly or unexpectedly. Some are open at the bottom for easy emptying. Others are closed and are removed when filled. Still others allow the adhesive (face plate or flange) to remain on the body while the pouch may be detached, washed out, and reused. Everyone needs some type of stoma pouch on hand, if only for emergency purposes.
A gauze or tissue can be folded neatly, touched with a small dollop of water-soluble lubricant, placed over the stoma and covered with a piece of plastic wrap. Such a dressing may be held on with micropore tape, underclothing, or an elastic garment. Plastic, ready-made stoma caps are also available. This method may be employed when colostomies behave predictably.
For the sake of convenience and discretion, keep all your equipment together on a shelf or in a small box or case.
It is a good idea to reorder supplies several weeks before you expect them to run out, to allow enough time for delivery.
You don’t have to use sterile supplies. For instance, facial tissue or cotton balls can substitute for gauze pads. The stoma and surrounding skin are not sterile and require only cleanliness.
In addition to the type of seal and proper appliance fit, there are several other factors which can influence how long the appliance will stay sealed. These include weather, skin peculiarity, scars, weight changes, diet, activity, body shape near the stoma, and the nature of the stool:
Some people with a descending or sigmoid colostomy find that by eating selected foods at specific intervals, they can make the bowel move at a time convenient to them, After a period of time, they may feel so certain of this schedule, they will wear a pouch only when a movement is expected. It may be possible to use this method as the only regulatory practice, or one may use it in addition to irrigation.
Irrigating to have regulated bowel movements is up to the individual, but it should be fully discussed with your physician or ET nurse before a decision is made. The irrigation procedure is taught with some variation, depending on the experience of the physician and the ET nurse teaching you.
Modern equipment consists of a plastic irrigating container with a long tube and a cone or tip to introduce water into the colostomy. An irrigation sleeve is worn to carry the irrigation returns into the toilet.