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What is an Ileostomy?

An ileostomy is a surgical procedure where the small intestine detaches from the large intestine. During surgery, the surgeon may remove either the total colon and rectum or a section of the small intestine. The ileostomy could be temporary if the procedure preserves the rectum and a portion of colon. Otherwise the ileostomy is permanent.

“The small intestine – which is about six meters long – is where most digestion takes place. Vitamins, minerals, proteins, fats, and carbohydrates are all absorbed into your body through your small intestine. Any food that is not absorbed in the small intestine goes into the large intestine as liquid waste or stool.”1

“An ileostomy is an intestinal stoma (from the Greek word for “mouth”), in which the ileum is attached to the abdominal wall surgically. This is done so the digestive waste then exits the body through this opening to which an appliance is attached to collect the intestinal succus.”2

What Causes an Ileostomy? 

“Various Indications for which intestinal stomas are formed: ulcerative colitis, bowel obstruction, cancer of colon & rectum, Crohn’s disease, congenital bowel defects, uncontrolled bleeding from large intestine, injury to the intestinal tract, inflammatory bowel disease, ischemic bowel disease, carcinoma urinary bladder and spinal cord injury.”3 

Types of Ileostomy

Conventional and continent are the two types of Ileostomy. Specialists perform end ileostomies as a part of an operation where they remove the large-bowel downstream no caudal viscus anastomoses to the ileum, which usually makes it a permanent device.

Conventional Ileostomy

The conventional or Brooke ileostomy consists in taking the terminal part of the small intestine that stays connected to the stomach and adhering it to an opening on the abdominal cavity. At that point, all undigested intake waste goes through that opening, called the stoma. In an ileostomy, the patient loses the sphincter that controls feces evacuation through the anus.

In a conventional ileostomy, the patient requires a bag to collect all the undigested body waste. The surgeon frequently extracts the remaining section of the ileum along with the colon and rectum.

“An ileostomy was first advocated in ulcerative colitis in 1912 but was not widely used until Brooke demonstrated his everted ileostomy in 1952.”3

An ileostomy can help patients with ulcerative colitis. “Brooke’s ileostomy still remains the procedure of choice for many patients with ulcerative colitis (UC) despite the advent of the ileal pouch-anal anastomosis procedure which allows many patients with UC to avoid having a permanent stoma.

However, for many patients with UC, an end ileostomy is still the preferred option after proctocolectomy, and it remains the highly preferred alternative if proctocolectomy is required for Crohn’s colitis.

Other common indications where a proctocolectomy and end ileostomy may be of benefit would be in conditions such as familial adenomatous polyposis, and extensive colonic resection for ischemia, cytomegalovirus or Clostridium difficile colitis.”2

Continent Ileostomy

In a continent Ileostomy (known as a Barnett Continent Intestinal Reservoir or BCIR), surgeons create an internal pouch and a valve from the lower end of the ileum (the small intestine). A stoma protrudes outside of the abdominal cavity, but only mucus flows out of it. Evacuation occurs 2-5 times daily through a tube inserted in the valve. The stoma may be covered with just a Band-Aid to contain and absorb any mucus.

What is the J-Pouch?

Another option to conventional ileostomy is called ileoanal pouch, also referred to as a J-pouch, ileoanal pouch, restorative proctocolectomy, pull through, and IPAA (ileal pouch-anal anastomosis).

“Since its introduction in the US in the 1980s, this procedure has undergone technical changes that make it much better tolerated, with improved outcomes and faster recovery. In selected individuals, it replaces total proctocolectomy with end ileostomy and allows for the retention of gastrointestinal continuity — a major concern for all patients.

Elective total proctocolectomy with J-pouch for UC is offered to patients who have precancerous or dysplastic colonic mucosal changes and to those patients refractory to medical management with intolerable symptoms such as frequency, pain, and urgency leading to a progressive decline in quality of life. Because the rate of synchronous or subsequent adenocarcinoma ranges from 10%-50% in this population, both high- and low-grade dysplasia constitute indications for proctocolectomy.”4

Ileostomy JPouch
Ileostomy JPouch

Indications for surgery in UC include refractory acute flares ; sudden, severe disease manifesting as an uncontrolled bleeding in the colon; toxic megacolon, and perforation of the bowel. 

The cure for UC is the removal of the diseased colon and rectum. This procedure requires resection of the colon and the upper portion of the rectum. It must preserve the anal canal and the sphincter so that  patients can resume normal bathroom routines. An internal pouch made of small intestine replaces the colon, and the surgeon stitches it on the partially empty rectum space (the perineum). A pouch is fashioned from the small intestine and sutured to the lower rectum.

This procedure allows patients to evacuate normally, without any supplies or tubes. A good result involves having a bowel movement 4-7 times a day, and being able to delay evacuation up to 45 minutes from feeling the urge. Postoperative complications include incontinence (unintended stool or gas escape), frequent bowel movements, or symptoms from the remaining lower rectum.

If a patient with an ileoanal J-pouch has a poor outcome, they could try converting to a Continent Ileostomy or a conventional ileostomy.

It is unclear whether Crohn’s disease patients are prospects for this procedure as the problem might spread to the pouch (pouchitis). Accordingly, an ileostomy is frequently the most fitting alternative.

An Ileostomy may be temporary or permanent

“An ileostomy may be temporary or permanent, depending on the medical reason for the surgery. Because of diseases – such as ulcerative colitis or Crohn’s Disease – the colon may be surgically removed, along with the rectum and anus.”1

Temporary Ileostomy

Temporary ileostomies often occur after partial colon dissection. Once the remaining colon heals, a specialist can restore the connection.

“Temporary diversion ileostomy is done to protect distal bowel anastomosis giving adequate time for the bowel repair to heal. Here we studied the reversal time for different temporary ileostomy done and found the factors causing a delay in the reversal of ileostomy.

Although it is said that temporary ileostomies are reversed within 6 to 12 weeks time, but reversal time is considerably delayed as what would be anticipated. Ileostomy carries considerable morbidity and psychological impact on the lifestyle of the patient. Non-reversal of ileostomy should be an important part of pre-procedural counseling because a considerable number of ostomies may not be reversed which were deemed to be temporary initially.”5

Permanent Ileostomy

Permanent ileostomies deal with chronic ulcerative colitis, bowel obstructions, colon cancer, rectal cancer, Crohn’s disease, congenital conditions, or trauma.

“Though a lifesaving procedure, it may result in a significant number of complications. Complications are divided into early complications (up to 30 days after the operation) and late complications (more than 30 days after the operation).”3

Rectal Cancer Sphincter and Ileostomy

“The gold-standard surgical treatment for mid to low rectal cancers is sphincter sparing anterior resection. During this, a temporary ileostomy is commonly formed to cover the pelvic anastomosis. Such practice aims to reduce sequelae of anastomotic leak, which includes increased morbidity, mortality and prolonged hospital stay. Unless precluded by patient comorbidity or patient preference, patients will undergo interval closure or reversal of ileostomy, thus restoring bowel continuity. Standard timing for reversal is considered to be 3 months, yet there is limited evidence to inform optimal time of reversal, with recent evidence suggesting that reversal may be safely performed as early as the first month following initial surgery

A defunctioning ileostomy is often formed during rectal cancer surgery to reduce the potentially fatal sequelae of anastomotic leak. Once the ileostomy is closed and bowel continuity restored, many patients can suffer poor bowel function, that is, low anterior resection syndrome (LARS). It has been suggested that delay to closure can increase the incidence of LARS which is known to significantly reduce the quality of life.

Clinical factors, surgeon and patient preference or service pressures May all impact time to closure”.6

Preoperative preparation

“Preoperative marking of the patient’s abdomen is important before surgery begins. Choosing an appropriate site is essential, and should be done by assessing the patient’s supine as well as in the sitting-up position in order to make any skin creases or folds more apparent. Ideally, the stoma site should be within the boundaries of the rectus abdominis muscle to minimize subsequent herniation. It should be 3 to 4 cm from any creases, bony prominences, scars, or the umbilicus to allow a smooth area to place the appliance. A common site to place the stoma is one-third of the way along a line drawn from the umbilicus to the anterior superior iliac spine. Once the surgeon and/or enterostomal therapist is happy with the evaluation, the skin is marked with a semi-permanent marker.

Preoperative preparation is vital for a successful operative outcome. Patients should not only be educated about the formal procedure and the potential complications but also meet with the enterostomal therapist to learn better about living with a stoma.”2

Postoperative Stool 

“Just after surgery, the stool from an ileostomy is generally a steady liquid type of drainage. However, as the small intestine begins to adapt, the stool will become thicker and more paste-like.

Remember the stool from an ileostomy comes directly from the small intestine, so the stool contains digestive enzymes that can be very irritating to your skin.

It is very important for the skin around the stoma to remain healthy and free of irritation. The peristomal skin should look just like the skin elsewhere on your abdomen. To prevent skin irritation or other skin problems, you should have a pouch that fits properly

There are some foods that can cause odor or gas in your system. Remember, the actual digestion of food takes place almost entirely in the small intestine, not in the colon. If that is a concern for you, you may want to eat those foods in moderation.”1

Lifestyle Tips

  • “Eat a balanced diet.
  • Eat slowly and chew your food well.
  • Add foods to your diet gradually, to see how those foods agree with your system.
  • Drink plenty of water, juice or other fluids each day.”1

Readmission

“New ileostomates have been reported to have higher readmission rates compared to other surgical patients.

Readmission is a prevalent and morbid problem for patients with new ileostomies, occurring in 28% within 60 days of surgery. Causes are heterogeneous, but dehydration is the most common. The strongest predictors of readmission at the time of discharge are comorbidity burden and serious inpatient complications. Readmissions in younger patients are more frequently for intra-peritoneal infections; these are difficult to predict and are primarily associated with serious inpatient complications. Readmission in patients over 65 years, however, are more frequently for potentially preventable conditions such as dehydration and UTI; for this cohort readmission is more easily predictable, and is associated with comorbidity, serious complications, living alone, prior intestinal surgery, loop stoma, and short length-of-stay. Patients should be risk-stratified prior to discharge—especially the elderly—and those at risk should be targeted for preventative interventions.”7 

Beware these Dehydration Signs in an Ostomate

  • “Feeling thirsty
  • Stomach cramping
  • Feeling dizzy or light-headed
  • Dry skin, mouth or tongue
  • Confusion
  • Dark-colored urine
  • Decreased urine output
  • Restless or agitated feelings.

How much fluid should you drink?

You need to drink more fluid than you did before your surgery. Usually, this means at least 2000 mL (8 cups) every day. Typically people need to drink an extra 500 mL-750 mL (2 – 3 cups).

Fluid needs will vary with ileostomy output.

Discuss your individual situation with the dietitian if you have diabetes, heart or kidney problems and/or fluid retention.

Ideas to help you manage your fluid intake:

  • Drink fluids throughout the day in order to maximize absorption.
  • Develop a schedule or pattern of drinking fluids (such as drinking a glass of fluid every 2 hours) and stick to it as much as possible.
  • Bring a beverage with you when you are going out.
  • Drink bottled water when traveling if water safety is questionable.

You will need to drink extra fluids when:

  • You have signs of dehydration (see above list).
  • Your ileostomy output is higher than usual.
  • You are sweating more than usual (example during hot weather)

Tips for prevention of food blockage – there are two main issues:

1) Particle size – Cut food up into smaller pieces and chew well. Cut long stringy food like celery and asparagus into shorter segments.

2) Ease of digestion – high fiber and thick-skinned foods take longer to digest and may travel intact further down toward your ileostomy

Food tolerance is very individual. A normal diet is often possible especially if you chew well. Swelling and inflammation decrease over time as your body recovers from surgery. About 6 weeks after your surgery, you will be ready to slowly return to your usual diet. Try one new food at a time. Start with a soft version and cut it into smaller than usual pieces. Wait a day before trying another new food. This way you will know how you react before you try something else. If a certain food causes a problem for you, avoid it for now, and then try it again in a few weeks. In other words, your body may react differently later.”8

A strict diet is unnecessary. After the procedure, the patient should gradually introduce food and in small quantities. Begin with a diet low in fiber, until reaching a normal diet. Avoid introducing new foods until the body tolerates the. The nurses should inform which foods produce flatulence and bad odor, and which they recommended. Seek an ostomy specialist or nurse for detailed information about diet and lifestyle tips with an ileostomy.

 

Reference:

 (1) Managing Your Ileostomy. http://www.hopitalmontfort.com/sites/default/files/PDF/colorectal-ileostomy.pdf 

(2) Brook’s Ileostomy. https://www.researchgate.net/publication/260135842_Brook’s_Ileostomy 

(3) A clinical study of intestinal stomas. https://www.ejmanager.com/mnstemps/93/93-1378259456.pdf 

(4) Total Proctocolectomy with J-pouch Reconstruction for Ulcerative Colitis https://www.pennmedicine.org/for-health-care-professionals/for-physicians/physician-education-and-resources/clinical-briefings/2018/february/total-proctocolectomy-with-jpouch-reconstruction-for-ulcerative-colitis 

(5) How temporary is a temporary ileostomy. https://ijsurgery.com/index.php/isj/article/view/3708

(6) Timing of ileostomy closure after anterior resection for rectal cancer. https://bmjopen.bmj.com/content/bmjopen/8/10/e023305.full.pdf 

(7) Readmission after ileostomy creation. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5397251/ 

(8) Nutrition after ileostomy surgery. https://vch.eduhealth.ca/PDFs/FK/FK.235.F739.pdf 

 

María Laura Márquez
13 October, 2018

Written by

María Laura Márquez, general doctor graduated from The University of Oriente in 2018, Venezuela. My interests in the world of medicine and science, are focused on surgery and its breakthroughs. Nowadays I practice my profession...read more:

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