IBD Case of the Month: Ostomy Developed by the CCFA Nurse and Advanced Practice Committee Author: Alexis Sherman RN BSN CWOCN Mount Sinai Hospital

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Introduction/Background 37yoF, diagnosed with ulcerative colitis, underwent ileal pouch anal anastomosis (J-pouch) 4 years later diagnosis changed to Crohn’s disease, underwent J-pouch excison with end ileostomy due to fistula formation in J-pouch Has undergone multiple revisions and re-sitings of ileostomy; most recent was 3 weeks ago due to peristomal abscess/fistula

Introduction/Background, cont’d 3 weeks post-op, patient presents to colorectal surgeon with separation of mucocutaneous junction; local wound care provided 10 days later, had increased drainage from wound and mild redness of peristomal skin; wound opened by surgeon

Mucocutaneous Separation Skin separates from stoma Common for pts on steroids, hx of radiation, poor nutritional status Treatment: Fill area with stomahesive powder and seal with skin sealant (3M cavilon) Avoid ostomy belt and convex appliance

What additional information would be helpful? Is her disease active or in remission? What medications is she on for Crohn’s disease? What type of ostomy appliance is she using and how often is she changing the appliance? Has the appliance been leaking? Does she have any product allergies?

Stoma /Peristomal Exam Red viable stoma, well budded Peristomal skin with deep ulceration on left side of stoma (3 o’clock) measuring 3cm, irregular in shape Draining purulent discharge Very painful Difficulty maintaining pouch seal and appliance very uncomfortable

What is the differential diagnosis? Pressure ulcer related to ostomy appliance Abscess Allergy to ostomy appliance Parastomal pyoderma gangrenosum (PG)

What should be ordered for workup? Biopsy to rule out malignancy Wound culture Labs Workup for active IBD Evaluation of stoma and appliance by an enterostomal therapist or certified wound ostomy continence nurse (CWOCN/ CWON/ COCN)

Peristomal pyoderma gangrenosum **** diagnosis of exclusion**** What is the Diagnosis? Peristomal pyoderma gangrenosum **** diagnosis of exclusion**** Very painful Rapid progression Full thickness ulcer

What is the plan of care? Involve GI for systemic treatment (anti-TNF?), dermatology for intralesional injections and CWOCN for pouching Ensure patient is using a non-convex pouching system to minimize trauma (pathergy) Eliminate ostomy support belt Educate patient on how to pouch stoma while addressing ulcers Pain control Emotional support

Pathergy Minor trauma or injury to the skin causes worsening of wound Examples Ostomy care related trauma Removal of appliance Convex appliance Ostomy belt

Consider use of 1 piece flexible appliance to minimize pressure Pouching Consider use of 1 piece flexible appliance to minimize pressure May need to increase frequency of appliance change to qd or qod due to use of ointments as well as volume of drainage from ulcers - Can be challenging as removing the appliance can worsen the ulcer and can be very painful Use of hydrofiber dressing fluffed into wound bed to absorb excess drainage and covered with thin hydrocolloid to allow for ostomy appliance to stick Consider use of 1 piece flexible appliance to minimize pressure May need to increase frequency of appliance change to q day or every other day Can be challenging as removing the appliance can worsen the ulcer

Fill ulcer with prescribed ointment or powder Pouching, cont’d Fill ulcer with prescribed ointment or powder -often tacrolimus (protopic powder) Use hydrofiber dressing fluffed into wound bed to absorb excess drainage Cover with thin hydrocolloid to allow for ostomy appliance to stick over dressing Other prescriptions include Cordran tape Use of hydrofiber dressing fluffed into wound bed to absorb excess drainage and covered with thin hydrocolloid to allow for ostomy appliance to stick Consider use of 1 piece flexible appliance to minimize pressure May need to increase frequency of appliance change to q day or every other day Can be challenging as removing the appliance can worsen the ulcer

What is the plan of care? If wound continues to spread or worsen, consider use of non-adhesive ostomy system to eliminate trauma from adhesive removal of appliance If continues to worsen despite proper pouching system, topical and systemic treatment, refer back to surgeon for re-siting of ostomy to other quadrant

Rapid Progression of Ulcer

Patient continued to have drainage from wound, opened by physician, and started on anti-TNF and steroid ointment

Despite steroid injections, adalimumab, and tacrolimus, ulcer spread 2 months after diagnosis of PG, stoma re-sited

Wound after stoma re-site 1 month after re-site Healed (4 months post-op) – scar formation due to full thickness ulcer

Summary Treatment of peristomal PG requires multidisciplinary approach involving ostomy nurse, GI, dermatology and possibly surgeon if requires re-siting Local and systemic treatments as well as proper pouching Lots of emotional support: pain and challenges to pouching affects quality of life Offer patient frequent follow-up with an enterostomal therapy nurse for assistance with pouching

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