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9/14/2018
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Welcome to the WCET® Webinar on Peristomal Complications by Janice Colwell RN, MS, CWOCN, FAAN
Denise Hibbert, RGN, MSc, BSc, STN, ONC, FSSCRSWCET Education Committee Chairperson
Webinar Moderator
Thank you to:
WCET® Education Committee
Jen Wood, WCET® Central Office Administrator
In Celebration of World Ostomy Day
WCET® thank Hollister® Journal Sustaining Partner
for Sponsorship of this Webinar on
“Current State of the Art and Science of PeristomalComplications”
by
Janice Colwell RN, MS, CWOCN, FAAN
9/14/2018
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and communities of practice
Membership Benefits
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Wound Education Toolkit
9/14/2018
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Skype: wcet.admin
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Suite 108
Washington, DC 20007
United States of America
• Phone: +1 202‐567‐3030
Fax: +1 202‐833‐3636
www.wcetn.org
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Current State of the Art and Science of Peristomal Complications
Janice Colwell, RN,MS,CWOCN,FAANAdvanced Practice Nurse
University of Chicago Medicine
Definition of Terms
• Peristomal Skin Complications (PSCs)– Skin inflammation, injury
or damage that occurs within 3-4 inches of the skin surface surrounding the stoma or
– Skin inflammation in the area covered by the pouching system
• Pouching system– Skin barrier
– Adhesive tape
– Skin barrier rings, paste, powder
– Skin barrier strips
– Other items used to secure the seal
• Ex: liquid skin barrier, adhesive sprays
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Types of Peristomal Skin
• Moisture Associated Skin Damage1
– Inflammation and denudation of the skin adjacent to a stoma associated with exposure to effluent such as urine or stool
• Medical Adhesive Related Injury2
– Erythema and/or other manifestation of cutaneous abnormality (including, but not limited to, vesicle, bulla, erosion, or tear) persists 30 minutes or more after removal of the adhesive
1Gray M, et al, 2013, JWOCN 2McNichol L, et al, 2013, JWOCN
Types of Peristomal Skin Complications
• Pressure1
– Medical device injury or from pressure such as clothing or activity
• Allergic Contact Dermatitis
– Inflammatory response to chemicals2
• Carcinoma
• Pressure ulcers
• Herpes
• Peristomal abscess
• Peristomal Pyoderma
• Fistula
1Salvadalena, , 2016, WOCN Core Curriculum
2Colwell & Beitz, 2007, JWOCN
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• Incidence/Prevalence – Ranges reported: 29-63% 1-4
– Many are unaware they have a problem 5-7
– 30% of visits to stoma clinic8
– Pain, high product usage, poor QOL and increase in cost 9-11
• Risk Factors:12
– Obesity and emergency surgery factors body mass index are at risk for stoma retraction and necrosis
– Surgeon experience and specialization are implicating factors for stoma-related complications, particularly in the emergently created stomas
– Diabetes, smoking, increased age
Peristomal Complications
1Arumugan et al, 2003, Colorectal Dis, 2Lindholm et al, 2013, JWOCN, 3Persson et al, 2010, Colorectal Dis, 4Salvadalena 2013 JWOCN, 5Herlufsen,e t al, 2006, Br J Nurs, 6Lyon et al, 2000, BJ Derm, 7Nybaek 2009, Act Derm Ven, 8Jemec et al 2008 Br J of Derm,9Meisner et al, 2012 Plos One, 10Nichols et al 2011 Gas Nrsg, 11Pittman et al, 2008 JWOCN, 12Steinhagen, et al. Intestinal Stomas: Postoperative Stoma Care & Peristomal Skin Complications Clin Colon Rectal Surg 2017;30:184–192.
Peristomal Skin Complications• Peristomal Moisture Associated Skin
Damage (PMASD)
– Irritant dermatitis
– Pseudoverrucous lesions
• Definition1
– Inflammation & erosion of skin adjacent & erosion of skin adjacent to the stoma
• Presentation:
– Skin loss reflective of exposure to stoma effluent
– Acute: partial thickness skin loss
– Chronic: hyperkeratosis
1Colwell & Beitz, 2007, JWOCNPhotographs by J. Colwell not for reprint
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Peristomal Skin Complications: PMASD
• Treatment: Identify Etiology
– Inappropriate size of skin barrier (skin barrier opening does not match stoma size/shape)
– Inappropriate fit of the skin barrier (convex vs non convex)
– Assess and adjust stoma volume and consistency
– Prolonged wear time (allowing erosion of the skin barrier)
PMASD Assessment
UrostomyFecal Stomas
Photographs by J. Colwell
not for reprint
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PMASD Assessment: Hyperplastic/ Pseudoverrucous
Photographs by J. Colwell
not for reprint
PMASD Assessment: Hyperplastic/ Pseudoverrucous
Photographs by J. Colwell
not for reprint
9/14/2018
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Peristomal Skin Complications: PMASD• Treatment: Identify the Etiology
– Inappropriate size of skin barrier (skin barrier opening does not match stoma size/shape)
– Round stoma
Photographs by J. Colwell
not for reprint
Peristomal Skin Complications: PMASD• Treatment: Identify the Etiology
– Inappropriate size of skin barrier (skin barrier opening does not match stoma size/shape)
– Oval stoma
Photographs by J. Colwell
not for reprint
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Peristomal Skin Complications: PMASD• Treatment: Identify Etiology
– Convex vs. Flat Skin Barriers
Flat
Photographs by J. Colwell not for reprint
Peristomal Skin Complications: PMASD• Treatment: Identify Etiology
– Convex vs. Flat Skin Barriers
Convex
Skin Folds
Skin Folds, Retraction
Skin Folds
Photographs by J. Colwell
not for reprint
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• Treatment: Identify Etiology– Assess and adjust stoma volume and consistency
• Considerations– High liquid output may erode the skin barrier
allowing stoma output onto the skin– Average ileostomy output = 1200 ccs/24 hours– Variable amount between 500-2000 ccs/24 hours
• Treatment options– Nutrition intervention– Medication– Patient
• Intake and output measurement• Weight
Peristomal Skin Complications: PMASD
Peristomal Skin Complications: PMASD
• Treatment: Identify the Etiology
– Prolonged wear time (allowing erosion of the skin barrier)
Photographs by J. Colwell
not for reprint
9/14/2018
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Definition:
– Erythema and/or other manifestation of cutaneous abnormality (including, but not limited to, vesicle, bulla, erosion, or tear) persists 30 minutes or more after removal of the adhesive
– Defined area of skin damage beneath adhesive
– Other terms: skin stripping, skin tears
Medical Adhesive Related Skin Injury (MARSI)
Photographs by J. Colwell not for reprint
Medical Adhesive Related Skin Injury (MARSI)
• Treatment Address Etiology:
– Adhesive releaser
– Adhesive remover
– Gentle removal
• Topical Treatment
– Thin hydrocolloid
Thin Hydrocolloid
Adhesive remover
Push Pull Removal
Photographs by J. Colwell
not for reprint
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PMASD: Topical Treatment
• Topical Treatment
– Skin barrier powder1
– Liquid skin barrier
– Thin hydrocolloid sheet
1Salavadalena, WOCN Core Curriculum, 2016
Photographs by J. Colwell
not for reprint
Peristomal Skin Complication
• History:
– 60 yr. old female
– Ulcerative colitis/Ileostomy for 20 years
– Kidney failure: transplant
– Lung failure: transplant
– Non healing peristomal issues
– Differential Dx
• Extended wear time
• Poor skin barrier fit
• Moisture associated skin damage
Photographs by J. Colwell
not for reprint
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Peristomal Skin Complication• Interventions
– Decreased wear time
– Increase fit around stoma
• Skin barrier rings/paste
• Extended wear barrier
– Considered: silver nitrate
– Topical: triamcinolone spray and crème
• Significant findings
– Pain in some areas
– Areas increasing in size
– All topical and therapies unsuccessful
• Biopsy of area
– Adenocarcinoma
Photographs by J. Colwell
not for reprint
• Bladder cancer
• Ileal conduit
• Hard firm painful peristomal area
• CT: metastatic disease
• Inflammatory bowel disease
• Using reusable equipment
• Presented with inability to maintain pouch seal
Peristomal Skin Complication: Cancer
Photographs by J. Colwell not for reprint
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PSC: Allergic Contact Dermatitis
• Identify offending agent
• Substitute product
• Topical: anti inflammatory
– Triaminicolone spray
• Oral antihistamine
Photographs by J. Colwell
not for reprint
PSCs: Pressure Ulcers/Injuries
• Morbidly obese patient with bladder cancer
• End loop with support bridge
• High marking
• Tension on the rod
• Left in for one month
• Result: pressure ulcer from support bridge
Photographs by J. Colwell not for reprint
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PSCs: Pressure Ulcers/Injuries
Photographs by J. Colwell
not for reprint
PSCs: Pressure Ulcers/Injuries
• Treatment: Address Etiology
– Fit of skin barrier
– Avoid convexity
• Consider light or soft if necessary
– No belt
• Topical Therapy
– Dressing choice
• Foam
• Thin hydrocolloid
Photographs by J. Colwell
not for reprint
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Historical Perspective• Evolution of Skin Barriers
– Karaya
– Hydrocolloids
– Standard wear barrier: sheet
Pouching Systems: Skin Barrier Options
• Stoma opening
– Cut to fit
– Precut
– Moldable
Precut
Moldable
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Pouching Systems: Skin Barrier Options
• Skin barrier shape
– Flat
– Convex
• Light
• Soft
• Deep
Hoeflok, et al JWOCN 2013
Pouching Systems: Skin Barrier Options
• Outer footprint
– Oval
– Round
– Square
Photographs by J. Colwell
not for reprint
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Pouching Systems: Skin Barrier Options
• Skin Barrier Material– Hydrocolloid
• Regular wear
• Extended wear
• Combination
• Skin Barrier Material– Infused
• Honey
• Ceramides
• Aloe vera
The basic principle of ostomy care: a consistent seal that provides
security and maintains the peristomal skin
Tool Box
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Peristomal Complications: Varices
• Etiology
– Portal hypertension
• Management
– Avoid pressure
– Careful removal
– Bleeding control
Photographs by J. Colwell
not for reprint
Peristomal Complication
• 32 year old female
• Crohn’s dx, status post proctocolectomy
• On no maintenance Crohn’s Disease medications
• Present with warm painful area next to stoma
• Differential Diagnosis:
• Pyoderma
• Abscess
• Other?
Photographs by J. Colwell
not for reprint
9/14/2018
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Peristomal Complication• Progressive pain, warmth
• Presentation with beige drainage
• Placed on antibiotics
• Ten days later developed stool from the area
• Final diagnosis: Crohn’s flare with fistula
Photographs by J. Colwell
not for reprint
Peristomal Complication
Peristomal Fistula
Photographs by J. Colwell
not for reprint
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Peristomal Abscess
Photographs by J. Colwell
not for reprint
Peristomal Skin Complication
• 98 year old male
• Rectal cancer/APR
• Colostomy
• Caregiver noted blisters
• Son sent image
Photographs by J. Colwell
not for reprint
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Peristomal Skin Complication:
• Treatment:
– Antiviral
– Burrow’s Solution soaks
– Adhesive releaser
Herpes
Photographs by J. Colwell
not for reprint
Peristomal Skin ComplicationsSnap Shot
• Cottam et al, 20071
– 3097=n– 34% developed problems
within 3 weeks after surgery
– Risk factors• Stoma height• BMI• Emergent surgery
• Carlsson et al, 20162
– 207=n– 23 (11%) developed
peristomal complications• 16-mild• 5-severe• 2-PPG
– Risk factors• Stoma related
– Stenosis– Opening at skin
level
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1Colorectal Diseases, 9(9); 834
2OWM, 62(10),34
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Peristomal Complications:What We Know
• Increase in the numbers of obese patients
• Many of the stoma patients have loop stomas
• Decrease in inpatient length of stay
• Lack of outpatient stoma patient follow up
• Limited resources outside of acute care
PSCs Implications• Pain / discomfort
• Complexity in management of ostomy care
• Quality of life may be reduced1
• Increase in healthcare costs2
1 Pittman J, et al. JWOCN, 2014 2 Meisner S et al. 2012 PloSOne.
Photographs by J. Colwell
not for reprint
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Peristomal Skin
• Goal should be maintaining peristomal skin integrity vs reactive (managing PSCs)
• How do we achieve:
– Education
– Product selection and adjustment
– Ongoing support
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Thank you!• To my patients who allow me to take images while they
are encountering problems
• To my patients who allow me to help them
• To WCET® for allowing me to spend some time with you all!
• My contact info: [email protected]
