Use of Colostomy Bags for Cancer Patients

Surgical Oncologist Dr Suneel Kaushik Komanduri explains how to take care of your colostomy bag or ileostomy bag, precautions to take while emptying it, and when to contact your doctor. 

What is a stoma?

A colostomy/ileostomy is an opening in the colon (large intestine) or ileal segment of the small intestine on the wall of abdomen (stomach) for passage of stools. The opening is called a stoma and is made by pulling the intestine to the skin surface and stitching the edges of the intestine to the skin.  These stomas divert the normal passage of stools. 

Stomas are made by a minor surgery. The stoma surprisingly has no pain sensation.  Your abdomen may be tender after surgery but the pain will go away over time. The feces exiting from the stomas are usually collected in a stoma bag and periodically emptied by the patient.

Why are stomas made?

The stomas divert the normal passage of faeces and allow it to exit your body. They are usually made by your doctor either as a temporary measure (may last for a few weeks to months) and can be reversed or as a permanent procedure that remains for long. 

• Temporary stomas are performed either to relieve the obstruction to stool passage in emergency (like in cancers of colon/rectum causing obstruction to passage of stools), to divert the feces from the site of surgery to allow sutures to heal etc. 
• Permanent stoma is made when the normal passage cannot be restored due to various reasons(like in an abdominoperineal resection surgery for cancer of rectum, or obstruction when the cause of obstruction cannot be relieved, sphincter tone is lost causing fecal incontinence etc.).

What are the different pouch systems available?

Different types of stoma pouch systems are available in the market. They can be a one piece or two piece system.

One piece system: 

This system consists of a skin barrier/wafer and a pouch joined together as a single unit. This requires changing the entire unit, including skin barrier, when the pouch is changed.

Frequent changes of ostomy appliances have the potential to cause skin irritation for some users. The frequent use and exchange of materials(skin barrier pastes, tapes and adhesive removers) can add additional expenses to your budget.

Two piece system:

This system consists of a skin barrier -called flange or wafer that remains in contact with the skin to which a stoma collecting pouch can be attached and locked.

The wafer will remain for an extended period and the stoma bag can be changed without actually removing the wafer every time you change the pouch. This however is more rigid, slightly more prone to leak, less flexible. It may sometimes be difficult to keep the flange clean.

Though costlier than the one piece system initially, the difference may not be much on a long run.

Ostomy bags can be drainable or closed bags. Closed bags available in one-piece or two-piece systems, are not reusable. Closed-end pouches are thrown away once the pouch is full. A drainable bag allows users to empty the contents of the pouch and then reuse.

Some ostomy bags have filters to clear the odour.

How often will the stool pass through? Can this be controlled?

Stool will pass from the stoma 3-6 times each day through a colostomy. May be more frequent in an ileostomy.  You probably will not feel the passage of stool and may be surprised at first when it functions or passes gas. The output will be more liquid-like initially and gradually solidifies and becomes more thicker with time as the body adapts to the new stoma. 

It is normal that you will not be able to control the frequency or timing like it can be done when it comes through the normal passage.

When and how to empty stoma bag? 

You will usually be taught how to empty the pouch before you leave the hospital. No sterile supplies are needed. It is advised to empty the pouch when it is 1/3 to ½ full to prevent it from bulging and leaking.

You may follow these steps when you empty the pouch:

1. You may empty the contents into a bowl or into the toilet.
2. Place yourself comfortably facing the toilet. 
3. Hold the bottom of the pouch up and release the clip on the tail of the pouch.
4. Unroll the tail and empty the contents. Release slowly to avoid splashing of the contents.
5. Clean the pouch and release gas within. Clean the outer surface with a tissue/toilet paper.
6. Roll up the tail end of the pouch and place the clip. Wash your hands.

 Will the stoma release much odour? How can it be controlled?

Many factors, such as foods, normal bacteria in your intestine, illness, certain medicines, and vitamins can cause odour.

• Some foods can produce more odour like eggs, cabbage, cheese, cucumber, onion, garlic, fish, dairy foods, and coffee etc. Avoiding or reducing their use may reduce odour from the stoma bag. It is better to avoid foods which bother you rather than taking them and feeling uncomfortable.
• An odour-resistant pouch may be helpful.
• Ensure that the skin barrier is stuck securely to your skin.
• Empty the pouch often.
• Deodorant liquids and/or tablets in the pouch may be helpful.
• There are some medicines you can take that may help. You can contact your doctor or nurse to discuss these products and how to use them. Certain things that help in decreasing bad odour are  bismuth subgallate, chlorophyll tablets, and bismuth subcarbonate. Keeping air deodorizers in that room can also control odour very well when you are emptying the pouch.

How frequently should it be changed?

Proper care of the stoma pouch with appropriate fixation and periodic emptying will prevent leakage. Usually a properly fitting stoma pouch will last for 1 week to 10 days. However, it is better to have a regular changing schedule once every 7-10 days instead of waiting for the leak to change the system.

It is preferred to change the system early in the morning when the bowel movements are less. It can also be performed 2-3 hrs after a previous meal when the bowel movements have slowed down.

How to ensure a proper fit?

The first step to a proper fitting pouch is a well placed stoma away from body folds. Your doctor shall place the stoma away from skin folds and bony prominences to ensure a proper fitting pouch. The pouch should be stuck around the stoma with a 2-3 mm gap all around and not more to prevent contact of stoma output with the skin.

The pouch should be well stuck. You may use barrier sheets or colopaste to ensure that the bag is well fixed. Emptying the pouch periodically and when it is less than half full will prevent it from leakage.

Have a regular schedule of changing the pouch system to avoid problems like leakage. Changing the pouch once in a week to ten days should be sufficient.

What problems can arise? When to consult a doctor?

Like many medical procedures, this stoma can be associated with a few complications/problems.

• Herniation or prolapse or edema (swelling due to accumulation of fluid) of stoma can cause difficulty in placing and retaining  the pouch. Consult your doctor for any surgical correction that may be required.
• Bleeding from the stoma can be occasional due to superficial injury. Usually is controlled spontaneously. Contact your doctor if bleeding is excess and recurrent.
• Sometimes the output is reduced or the stoma may stop functioning. This could be a serious problem if persistent. It could be a sign of an underlying pathology.  
• Skin irritation, infection and erosions of surrounding skin. This is commonly seen with ileostomy. This will require the pouch to be properly placed and require use of barriers to avoid contact of digestive enzymes with the skin to prevent these changes. 

How to manage at a social gathering?

Most often the pouch can be covered under your clothes. Use odour absorbent and follow dietary advice discussed to reduce the odour. Make sure the pouch is well stuck and without any leakage.

You may prefer to empty the pouch prior to joining the gathering. Irrigating the stoma with saline or water may keep it dry. Always carry an extra piece of stoma bag just in case you may need to change. With adequate preparation you will be well able to enjoy your time with your loved ones.