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Words on Wounds

A forum to discuss the latest news and ideas in skin and wound care.

Thursday, August 15, 2019

Wound CSI
Jane came to our ostomy clinic. She was complaining that her ostomy appliance was not “sticky to the skin any more." leading to frequent leakage. On examination, the stoma appeared red, moist, and shiny; providers noticed an increased in size and length of the stoma. There was a pronounced protuberance in the left lower quadrant of the abdomen and an out-pouching area completely surrounding the stoma. What is the diagnosis?

CSI 8-15-19.png

This is peristomal herniation (PSH) with stoma prolapse. PSH is characterized by the protrusion of abdominal contents through the fascial defect that was incised to bring the intestine through the abdominal wall to form the stoma into the subcutaneous tissue. It is the most frequent complication of stomas and develops in up to 50% of patients. Although most PSH occurs within 2 years of ostomy creation, PSH can occur up to 30 years after surgery. With aging, the rectus abdominus muscle becomes thinner and weaker, affecting support for a stoma. Although the etiology is likely to be multifactorial, an oversized opening for the stoma in the muscle and fascia at time of surgery is a primary cause. Other predisposing or risk factors include increased BMI, increased waist circumference, respiratory comorbidity, diabetes mellitus, chronic cough or constipation, ascites, corticosteroid use, postoperative wound sepsis, and/or the presence of other abdominal wall hernias. Stomas constructed through the rectus abdominus muscle are less likely to develop PSH than those constructed lateral to the rectus abdominus muscle.   

Depending on the severity of PSH, the appliance may not conform to the contour of the herniated area, resulting in subsequent leakage. Leakage is one of the most common problems for those living with PSH; stretching and relaxing of the peristomal skin with changes in position make it challenging to maintain a good pouch seal. 

Recommendations: 
Use of a flexible appliance that is more likely to conform to the contour. 
Abdominal support belts or girdles. 
No heavy lifting. 
Exercise to strengthen abdominal muscles. 
Weight reduction to achieve a body mass index of 20 to 25. 
Surgery may be required.