Pediatric emergency medicine trisk 1171

up to the skin below the umbilicus to serve as a vent for high bladder pressure,
and it is protective of the upper urinary tract.
Ureterostomy is accomplished by bringing the ureter to the surface of the skin
either in the groin (low) or in the flank (high). Most high ureterostomies are of the
loop variety, in which a loop of the ureter is incised on one side and passed
upward to allow the edges to be anastomosed to the skin. This path allows
ureteral continuity from the kidney to the bladder, with a vent to the skin. Low
ureterostomies are more common and are performed for obstructed ureters such
as ectopic ureters or megaureters. To decompress an obstructed system and
prevent urinary tract infection, the ureter is divided, the distal end is ligated, and
the proximal edges are anastomosed to the skin.
Ileal loop conduits are created with a resected 10- to 20-cm H2 O bowel
segment of the ileum and anastomosing both ureters to one end. The other end of
the bowel loop is brought out to the skin. Ileal loop conduits are preferable in
older children who can wear an appliance to collect the urine.

Equipment
Standard ostomies are commonly managed by placing an ostomy pouch over the
stoma to collect the effluent. In young infants, sigmoid colostomies may be
managed without an external pouch if the effluent is not caustic to the skin and
fluid is therefore collected in the diaper. Urinary flow can also be collected in a
diaper and may be preferable because some appliances do not adhere well to the
skin for long periods.
Ostomy pouches for children are manufactured in various sizes. One- and twopiece configurations are available, and pouches may be soft or rigid.
Supplemental adhesives are crucial to enhance adhesion, especially if the effluent
is more liquid like.

Clinical Findings/Management
Gastrointestinal Diversions
Patients with colostomies and ileostomies may present with complications that
are common to both types of ostomies. Ileostomies also have metabolic

complications that are specific to this type of ostomy.
Cutaneous Complications. Peristomal cutaneous complications are common in
patients with ostomies, and stem from the effect of chronic stool and other
drainage on the peristomal skin. This chronic drainage compromises the skin
integrity surrounding the stoma. The most effective management is the


maintenance of a good seal between the ostomy pouch and the stoma. Contact
dermatitis may occur either from leakage around the stoma or from allergy to
stomal materials such as tape or pouches. Removing the offending material often
successfully treats this condition. Infection with C. albicans is fairly common
because of the persistent moisture and the frequent use of antibiotics. Treatment
with antifungal agents such as clotrimazole, especially powders, is effective. The
powder can be mixed with a small amount of water and painted onto the skin to
enhance adherence of the pouch. Ointments and creams should be avoided in
fungal infections. Skin bleeding resulting from prolonged irritation of the
peristomal area is usually minor. The cellulitis that can occur if the skin
excoriation worsens is treated with systemic antibiotics.
Stomal Complications. Stomal stenosis is not always detectable to the parent or
practitioner and may present with reduced or absent output, diarrhea, or cramping
abdominal pain. When severe stenosis occurs, it usually presents as obstruction.
To assess the degree of stenosis, the physician should gently examine the stoma
digitally unless the stoma is too small. In this case, a catheter should be carefully
passed. If abdominal obstruction is suspected, radiographs of the abdomen and
urgent surgical consultation are indicated.
Prolapse of the stoma occurs in more than 20% of patients with stomas and is
usually not an emergency. However, skin excoriation, bleeding, and incarceration
of the bowel may occur. The situation becomes more urgent if the prolapse is
associated with pain, decreased output, or a dusky stoma color that represents
circulatory compromise; this requires immediate surgical management. This

includes easing the prolapsed contents back into the stoma using both hands. This
procedure may need to be done repetitively until such time that definitive surgical
repair is undertaken.
Retraction of the stoma because of excessive tension may cause the stoma to
recede beneath the skin. This condition occurs more often than prolapse in
patients with ileostomies. Stomal retraction makes it difficult for a pouch to
adhere to the skin. Retraction can also result in cellulitis or even peritonitis,
depending on the location of the detachment and the flow of the effluent.
Management usually includes antibiotics and if the retraction is extensive,
surgical correction is indicated.
A hernia of the peristomal contents occurs when there is a protrusion of the
colon or ileum into the subcutaneous layers of skin surrounding the stoma. This
complication may impede adherence of the ostomy pouch but does not usually


represent an emergency. Elective surgical revision provides definitive
management.
Complications Specific to Ileostomy. Patients with ileostomies occasionally
develop metabolic derangements. In the face of large volume losses, children tend
to deplete salt and water. If large fluid losses persist, the biochemical profiles of
these patients are significantly altered. Determining the cause of the exceptionally
high fluid losses from the ileostomy is crucial. Some possibilities are obstruction,
gastroenteritis, and dietary indiscretion. Treatment is aimed at restoring normal
fluid and electrolyte balance and may require hospital admission.
Patients with ileostomies are prone to acquiring urinary stones. The chemical
composition of stones in this scenario is different than that in normal patients;
uric acid stones constitute 60% and calcium oxalate makes up the remainder.
Treatment is directed at decreasing ileostomy output and increasing urine output.

Urinary Diversions

Vesicostomy
In patients with a vesicostomy, eversion of a large portion of the bladder can
occur and appear like an exstrophy. When the posterior aspect of the bladder
prolapses through the stoma, the patient presents with a red mass, which may
change to purple if not treated promptly. Applying an index fingertip to the
bladder and gently pushing inward may manage this condition. Nonlatex gloves
are required because children with urologic abnormalities are often allergic to
latex. Sedatives may be required to facilitate reduction of the prolapse. A
prolapsed vesicostomy should be surgically revised emergently if the manual
reduction is unsuccessful.
Patients with stomal stenosis of the vesicostomy usually present with a
palpable bladder, a history of unwanted urethral voiding, or with symptoms of
urinary tract infection. As the bladder fails to empty at low pressures, the mean
storage pressure rises and the chance for seeding bacteria into the upper urinary
tract increases. These patients often have a pinpoint opening to the bladder, and
the parents usually comment on how much smaller the stoma has become over
time. If possible, these patients should have a catheter placed via the vesicostomy
using a small (6F or 8F) catheter. If it is not possible to catheterize the
vesicostomy, an attempt must be made at urethral catheterization assuming the
patient has been left anatomically intact. If the vesicostomy is successfully
catheterized, the catheter should be left in place until surgical revision is carried
out.


Many vesicostomies are colonized with bacteria via stomal contamination.
Therefore, a catheterized specimen through the stoma is sometimes unreliable.
Patients with constitutional symptoms such as fever should have their urine
culture carried out via vesicostomy. If no other source of fever is discovered,
treatment should commence after the culture has been obtained. In an
asymptomatic patient, a positive culture result may represent asymptomatic

bacteriuria and is not always of concern.
Skin irritation in the area of the vesicostomy is unusual. The most important
preventive measure is frequent diaper changes, even if highly absorbent diapers
are used. If urine seeps onto the patient’s clothes repetitively, skin breakdown
may ensue. In severe cases, temporary urinary diversion with a Foley catheter
while applying a barrier ointment allows time for healing.
Ureterostomy
Stenosis is the most common complication in the patient with a ureterostomy.
These patients often present with fever and symptoms suggestive of
pyelonephritis. The stoma should be catheterized with an 8F catheter, and urine
should be sent for culture. Surgical revision of the stoma or definitive urologic
reconstruction must be considered. Ureterostomy prolapse is rare.
Ileal Loop Conduits
Inflammation of the peristomal skin arises when the appliance fits poorly around
this bud of ileum, allowing urine to seep under the protective wafer. Prolonged
contact with skin causes irritation and ulceration. The use of paste to create a
better seal around the bud is often all that is needed to avoid such a complication.
In some cases, surgical revision is necessary, especially when the bud has
retracted.
Prolapse of the ileum occurs occasionally and can be striking, especially if too
long a segment was used in creating the loop initially. Prolapsed segments 20 to
30 cm H2 O long have been seen and require surgical revision. If the prolapse is
minor, the clinician should perform the same gentle manual reduction technique
previously described in the “Stomal Complications” section under
“Gastrointestinal Diversions.”
Peristomal hernia can occur when fascial defects adjacent to the ileal loop
allow loops of bowel to herniate outside the abdominal wall. This condition
requires urgent surgical consultation.
Stenosis of the ileal stoma may occur in these patients. Symptoms may include
pain, but the usual presenting complaint for these patients is fever. This finding