Ileostomy Site Research Articles

Peristomal varices – life threatening or luminal?

Bleeding from the edge of an ileostomy site is a common problem. In those who have undergone a proctocolectomy with ileostomy formation in conjunction with a risk of chronic liver disease (even with normal liver function tests), this may be due to peristomal varices. If this is the case, significant, difficult-to-control and potentially life-threatening bleeding is likely in the future and may require transfusion. Improvements in radiological imaging techniques can give quick, sensitive and specific information to diagnose and guide management in this group. In those patients with major bleeding episodes, an initial conservative management policy should be adopted with the knowledge that, if bleeding persists, propanolol therapy, portosystemic shunt insertion or even liver transplantation may be indicated.

Ileostomy Adenocarcinomas in the Setting of Ulcerative Colitis

Adenocarcinomas arising at ileostomy sites in patients after colon resection for various diseases, such as ulcerative colitis (UC), familial adenomatous polyposis coli, and Crohn's disease, are rare occurrences but have been reported increasingly in the last 20 years. We report a case of adenocarcinoma arising in an ileostomy site in an 85-year-old woman with longstanding UC. She had pancolitis and underwent total proctocolectomy. Thirty-nine years later, her ileostomy site developed a granulation tissue-type lesion, which on initial biopsy revealed cytologic atypia in the presence of marked inflammation. A subsequent biopsy revealed adenocarcinoma with signet-ring cells and abundant extracellular mucin. Resection of the ileostomy was undertaken and a new ileostomy was performed. The literature on adenocarcinoma arising in the 23 patients with ulcerative colitis who received a Brooke or Kock ileostomy and had no prior history of neoplasm is reviewed.

Epidermotropic Mucinous Adenocarcinoma Arising at Mucocutaneous Stomal Anastomosis Site

Polypoid lesions arising at ileostomy sites are uncommon and include inflammatory polyps related to prolapse and neoplastic polyps. Primary mucinous adenocarcinoma arising at an ileostomy site is rare and usually occurs in longstanding ulcerative colitis. An 82‐year‐old woman presented with an erythematous 1.5 cm polyp at the mucocutaneous junction of her ileostomy. Her history is significant for a cystectomy with ileal loop 23 years earlier for transitional cell carcinoma of the bladder. She had no prior history of ulcerative colitis. Histologically, a polypoid lesion was produced by variable‐sized cystic spaces filled with mucin and lined by columnar epithelium with goblet cells. The epithelial cells demonstrated cytological atypia and occasional mitotic figures were observed. Smaller neoplastic glands infiltrated the dermis and scattered, multiple epidermotropic foci were noted. We present an unusual case of a primary mucinous adenocarcinoma with multiple epidermotropic foci arising at an ileostomy site in a patient without a known history of ulcerative colitis. Primary mucinous adenocarcinoma arising at an ileostomy site is a rare occurrence described primarily in the gastrointestinal literature but could easily be unrecognized by a dermatopathologist. Knowledge of this phenomenon may prove helpful in arriving at the correct diagnosis.

P0352 RECURRENT GI BLEEDING FROM ???IATROGENIC??? VARIX IN GASTROSTOMY-RESOLUTION BY SURGICAL CLOSURE

Introduction: Gastrointestinal (GI) bleeding from varices is the most significant complication of portal hypertension. Varices occur at the sites where portal and systemic circulation are in close proximity. The natural sites for the development of varices are in the lower esophagus, retroperitoneum, hemorrhoidal venous plexus, and umbilical vein. Varices have also been reported around colostomy and ileostomy sites. We have observed significant bleeding from varices that have developed in the gas-trostomy tract in a patient with portal hypertension. Methods: We report our experience with a patient with history of portal hypertension and repeated admissions at Loma Linda University for the management of upper GI bleeding. The bleeding was found to be from varices in the gastrostomy tract. Results: This is a five-year old female, who initially presented at eight months of age, with history of Jeune’s Syndrome, ventilator dependence, micronodular cirrhosis, portal hypertension, and anemia secondary to recurrent upper GI bleeding. Upper endoscopy revealed non-bleeding esophageal varices and a possible varix in gastrostomy tract. Over the next five months, she required frequent admissions for management of bleeding and required multiple blood transfusions. At thirteen months of age, patient presented with massive upper GI bleeding and a repeat upper endoscopy showed non-bleeding esophageal and gastric varices, and bleeding from a protruding varix from gastrostomy site. Patient was referred to pediatric surgery, and had resection of gastrostomy tract. Since surgical intervention, patient has had no further recurrence of upper GI bleeding in the ensuing four years. Conclusion: A surgical procedure such as gastrostomy can result in the development of portal-systemic collaterals by artificially creating proximity between the portal and systemic venous circulation in patients with portal hypertension. These collaterals could cause significant bleeding, resulting in increased morbidity. Surgical resection of the gastrostomy tract can remove a source of bleeding from varices located around the stoma and potentially reduce the morbidity associated with bleeding in patients with portal hypertension. Non-surgical methods of providing enteral feedings should be considered in patients with portal hypertension and feeding disorder.

3553 Sclerotherapy for stomal varices: bleeding controlled.

Sclerotherapy is one of the standard protocols available for esophageal varices to control bleeding and reduce risk of re-bleeding. It's utility is less clear in other vascular lesions. Control of bleeding in patients (PTS) with ileostomy site stomal varices is directed at lowering filling pressure by shunting portal hypertensive blood away from bleeding collateral vessels. This is more difficult in PTS with portal vein thrombosis.We describe use of ultrasound guided sclerotherapy in five PTS to control stomal variceal bleeding. All had ileostomies during total colectomy for ulcerative colitis. Two PTS had developed pancreatic cancer decades after surgery and both had portal vein thrombosis, a complication of the malignancy. TECHNIQUE: All PTS were treated by a single care provider. PTS were NPO for eight hours before ultrasound, to reduce ostomy output. The stomal site was photographed before treatment was initiated. Venous and arterial collateral vessels were mapped out around the stoma to define high flow conduits with the bleeding site. Mid-clavicular line was defined as 12:00. Initial site selected was vessel closest to the active bleeding site. Preference was to vessels >3 mm in diameter. Direction of flow did not affect choice of vessel. The site was injected while compressing the vessel to prevent flow away from the stoma, thereby encouraging the sclerosant to propagate toward the stoma. All injections were inside vessels, not around margins of vessels. Treatments were at six week intervals, or PRN if bleeding developed. PTS were followed to demise or until liver transplant(Tx). RESULTS: Five PTS were treated. Female to male ratio was 2:3. Ages were 58-78 yrs. Two to six treatments were required to demonstrate loss of vessels >1.5 mm in diameter. Transfusion requirements varied between 5 & 26 units per yr. before sclerotherapy, with a decrease to 0-4 units per year after completion. One patient had bleeding from esophageal varices during followup period. One patient awaits a Tx while one has already undergone Tx. The 2 PTS with pancreatic cancer and portal vein thrombosis lived 4 & 6 months respectively, after completing therapy. Each required 2 treatment cycles. CONCLUSION: Stomal varices can be treated successfully with sclerosing therapy. Access to the vessel in continuity with the stoma bleeding site requires ultrasound guidance. This therapy is indeed worthwhile and effective in controlling ileostomy stomal bleeding.

A CASE REPORT OF SQUAMOUS CELL CARCINOMA AT THE COLOSTOMY SITE

Tumor at the intestinal stoma site has been reported as one of the late complications of stomas. There have been very few reports about malignant tumors except adenocarcinomas originating from the colostomy site after abdominal-perineal resection for rectal cancer, and the ileostomy site after total colectomy for familial polyposis coli (FAP) or ulcertive colitis (UC). We present here an interesting case of squamous cell carcinoma at the colostomy site. The patient was a 58-year-old woman on hemodialysis chronically. She had been colostomised for atresia ani on the 21 st day after birth and colostomy had been reconstructioned because of ileus when she was 26 years old. Recently, granulation tissues were growing around her stoma site and she had been treated with electrocoagulation. After she was transferred to the hospital, a peristomal polypoid tumor appeared and grew to golfball size in about 10 months. Though we could not prove it malignant by a biopsy, the polypoid tumor easily bled and disturbed to use colostomy pouching systems. So it was resected under epidural anesthesia. Pathological diagnosis of the excised material was well differentiated squamous cell carcinoma. We speculated that the high carcinogenesis in the hemodialyzed patients and chronic irritation to the skin around the colostomy might participate in development of the tumor.

Stapled Ileoanal Anastomosis for Ulcerative Colitis and Familial Polyposis Without a Temporary Diverting Ileostomy

Between March 1989 and August 1990, we performed 21 stapled J pouch ileonal procedures (20 ulcerative colitis [UC], 1 familial polyposis [FP]) without an ileostomy in 19, of whom 13 were taking prednisone and eight underwent semi-emergent surgery for uncontrollable bleeding. During the same time, an additional four patients required a standard ileonal procedure. The results of anal manometry and clinical function were compared to 25 patients who had previously undergone mucosal stripping and a sutured J pouch ileoanal anastomoses with a temporary diverting ileostomy between October 1982 and August 1990. During this same time period, an additional 19 patients underwent an anti-peristaltic reversed J pouch and 18 an S pouch, for a total of 83 ileoanal procedures. The reversed J pouch had a lower stool frequency than a standard J pouch but had an unacceptable incidence of complications and problems with pouch emptying. The S pouch had a stool frequency similar to the standard J pouch but provided greater length in patients with a short mesentery. Stapled J pouch ileoanal patients had a better (p less than 0.02) maximum and sphincter resting pressure (46 +/- 11 versus 34 +/- 12 mmHg), fewer (p less than 0.05) night-time accidents (22% versus 68%), daytime (17% versus 55%) or night-time (28 versus 61%) spotting, or use of a protective pad at night (11% versus 42%) than nonstapled J pouch ileoanal patients. Stool frequency was similar in the two groups. All but one UC patient had residual disease at the anastomosis. Anal mucosa between the dentate line and stapled anastomosis was 1.8 +/- 1.3 cm (range, 0 to 3.5 cm). Complications in the nonstapled J pouch group included 4 pouches excised (2 for complications, 2 for excessive stool frequency), 1 pelvic abscess, 2 stenosis requiring dilation under anesthesia, 1 enterocutaneous fistula after ileostomy closure, 1 ileostomy site hernia, and 2 small bowel obstructions. Of the 65 patients who underwent ileostomy closure in the entire series, 8 (12%) developed a complication requiring surgical intervention. Complications in the stapled group included 1 anastomotic leak, 1 pouch leak, and 1 pelvic abscess. Patients were managed successfully with drainage (all 3) and diverting ileostomy (1). One patient developed stenosis requiring dilation under anesthesia. The stapled J pouch ileoanal anastomosis is a simpler, safer procedure with less tension than a standard handsewn J pouch but leaves a very small cuff of residual disease. It provides significantly better stool control and may obviate the need for an ileostomy with its complications.

Volatile fatty acids in the human intestine: Studies in surgical patients

Volatile fatty acids (VFA) were measured in digesta taken from the stomata of 39 patients who had undergone large bowel surgery. Total VFA were highest in patients with transverse colostomy and lowest with ileostomy. Levels were intermediate in sigmoid colostomy patients and the same as in faeces from normal controls. The only acid present at the ileostomy site was acetate but in all other samples propionate and butyrate together contributed 30–40% of the total. Neither total nor individual VFA concentrations at any stomal site were related to total fibre intake.

Adenocarcinoma of an Ileostomy Site With Skin Invasion: A Case Report

A case is reported of an adenocarcinoma arising in an ileostomy site 32 yr after a staged proctocolectomy for ulcerative colitis. As in 2 of the 3 previously reported cases of Ileostomy carcinoma, a locally invasive tumor produced Ileostomy retraction and stenosis with peristomal pain and ulceration but no intestinal obstruction or metastatic spread. When an ileostomy requires late revision for inflammatory changes, careful pathologic examination of the entire resected stoma and surrounding skin is essential.

Adenocarcinoma arising at an ileostomy site. Report of a case

A case is reported of a 60-year-old man, who developed an adenocarcinoma in the abdominal wall adjoining an ileostomy. Thirty-one years previously a total colectomy was performed for ulcerative colitis. Because of extensive prolapse the ileostomy was excised 6 years before the final operation, and a fresh part of the ileum, 10 cm proximal to the original stoma, was reimplanted in the abdominal wall at the same location. The pathogenesis of the malignant growth is uncertain; several possibilities as to the course of events at the ileostomy and surrounding skin are discussed.