Day: March 29, 2021

What Are Indications for a Ileostomy?

Patient Presentation
A 19-year-old male with a history of ulcerative colitis, who had an ileostomy after a partial colectomy was presented at the pediatric resident teaching conference. The ostomy had become high output and he was admitted for fluid and electrolyte management to the surgical service. The presenting resident had done a consultation for the surgical service for the concern of sexually transmitted infection treatment. “We took care of the STI issues, but it was very interesting to read his chart and see the ostomy because we usually don’t see these patients. Surgery takes care of them or the GI specialty nurses. It was interesting to see the two ends of the ileum in the one hole, and see how the ostomy bags are managed. Unfortunately with the high-out problem he’s also having a lot of skin irritation too.”

Discussion
There are three types of inflammatory bowel disease (IBD):

  • Crohn’s disease (CD) – can affect entire gastrointestinal tract but often is discontinuous (i.e., has skipped areas), has transmural inflammation and disease, has granulomas
  • Ulcerative colitis (UC) – affects the colon, is continuous (i.e., has no skipped areas) and has superficial mucosal ulcerations
  • Unclassified IBD – has chronic colitis but not specific features of CD or UC

The specific pathogenesis appears to be multifactorial with having a genetic predisposition (1.6 – 30% risk of developing UC if patient has first degree relative), the gut microbiome, the body’s inflammatory response and the overall external environment as factors. Patients can have malnutrition (more common in CD), linear growth impairment and have an increased risk of cancer (including colorectal, lymphoma and non-melanoma skin cancer). Patients have an increased risk of depression, anxiety, and feeling of lack of control in their lives. In some studies, patients with IBD have higher academic achievement and higher annual incomes. There has been an increased incidence of pediatric IBD and especially CD over the last few decades. There also seems to be a latitudinal gradient with more patients in northern latitudes than southern ones.

Ulcerative colitis often presents with increased bowel movements (including at night), stooling urgency, mucousy or bloody stools and abdominal pain. Patients may also have fatigue. Unlike CD they generally will not have malnutrition. Treatment goals are to induce and maintain disease remission, minimize disease or treatment complications, prevent surgery if possible, maintain nutrition, and optimize overall growth, health and normal lifestyle as much as possible. Treatment usually uses anti-inflammatory medications to induce and maintain remission. Unfortunately many patients with IBD become steroid dependent (10-50% for UC patients), but biological therapies have decreased steroid-complications for many patients. UC can be “cured” with colectomy as if there is no colon and rectum then there is no UC, but this also means a patient is then ileostomy dependent for the rest of their lives. Unfortunately, the older the pediatric patient is when diagnosed with UC the more likely they are to need a colectomy at some point in their life (~20% for patients diagnosed after age 10 years). More patients may need surgery at some point in their life (up to 45%). Surgery can be an emergency because of colonic perforation, severe bleeding or toxic megacolon. Non-emergent reasons may be poorly controlled colitis despite medical treatment, patient desire, and nutritional status. There are many different types of proctocolectomies but if maintaining intestinal continuity is a goal, then the anus is maintained and an anastomosis with or without a “pouch” acting as a stool reservoir is created. Complication rates for these surgeries are high (20-50%) and include anastomotic leak, dehiscence, pouchitis, deep venous thrombosis, mesenteric venous thrombosis, increased risk of pouch dysplasia and cancer. A diverting ileostomy may be created as part of these surgeries.

Learning Point
An ileostomy is a surgical diverting procedure where the ileum of the small bowel is brought through a surgical opening in the abdominal wall.
The ileostomy can be temporary or permanent.
Ileostomy indications include:

  • To permanently evacuate the stool when a permanent protocolectomy is performed and a direct anastomosis from the ileum to the abdominal wall is made. This is a single lumen ileostomy.
  • To defunction the distal bowel temporarily to protect a distal surgical anastomosis allowing that anastomosis time to heal. Often a dual opening on the abdominal wall is made where ileum is severed and the proximal ileal lumen attached to the abdomen evacuates the stool and the distal ileum lumen also attached to the abdomen evacuates mucous from the colon. The two lumens lie next to each other through one opening on the abdominal wall.
  • To relieve a bowel obstruction. This is usually a temporary ileostomy.

Ileostomy contraindications are relative and basically due to anatomic problems such as a short mesentary not allowing enough mobilization of the ileum to reach the abdominal wall.
There are some surgical differences depending on the patient’s particular anatomy, size, reason for the ileostomy, etc. Retention of the distal ileum and ileocecal valve is preferred as they are important for nutrition and management of gut mechanics.

Potential problems of ileostomies include infection/abscess, ischemia/necrosis, hemorrhage, retraction/prolapse/hernia formation, stenosis or obstruction, fistula formation and skin irritation.
There can also be electrolyte or dehydration problems if there is high output stool flow. Normal ileostomy output is 200-700 ml/day for adults.

Questions for Further Discussion
1. How is Crohn’s disease different or the same from ulcerative colitis?
2. What is irritable bowel syndrome? A review can be found here
3. What are common skin problems and how are they managed for a patient with an ostomy?

Related Cases

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Evidence-based medicine information on this topic can be found at SearchingPediatrics.com and the Cochrane Database of Systematic Reviews.

Information prescriptions for patients can be found at MedlinePlus for these topics: Ostomy and Ulcerative Colitis.

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

To view videos related to this topic check YouTube Videos.

Wilson DC, Russell RK. Overview of paediatric IBD. Semin Pediatr Surg. 2017;26(6):344-348. doi:10.1053/j.sempedsurg.2017.10.002


Ryan DP, Doody DP. Surgical options in the treatment of ulcerative colitis. Semin Pediatr Surg. 2017;26(6):379-383. doi:10.1053/j.sempedsurg.2017.10.001


Nasiri S, Kuenzig ME, Benchimol EI. Long-term outcomes of pediatric inflammatory bowel disease. Semin Pediatr Surg. 2017;26(6):398-404. doi:10.1053/j.sempedsurg.2017.10.010


Rajaretnam N, Lieske B. Ileostomy. In: StatPearls. StatPearls Publishing; 2020. Accessed January 4, 2021. http://www.ncbi.nlm.nih.gov/books/NBK519003/


Overview of Ulcerative Colitis | Crohn’s & Colitis Foundation. Accessed January 4, 2021. https://www.crohnscolitisfoundation.org/what-is-ulcerative-colitis/overview

Author
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa