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

2. Instructions
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3. 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

4. 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

5. 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

6. 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?

7. 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

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

9. 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)

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

11. 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

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

13. 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

14. 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

15. 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

16. Rapid Progression of Ulcer

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

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

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

20. 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

21. Thank you!
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