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Patient with jejunostomy, caput medusae, and bleeding peristomal varices
OPT QNS IN PRACTCE FEATURE EDITOR: Maureen Hanlon, RN, MN, CETN
Ptions in Practice presents different m a n a g e m e n t a p p r o a c h e s to the same clinical situation.You are invited to submit a brief case description, i n c l u d i n g the specialty nursing c a r e provided, a n d several glossy, color photographs of the clinical situation. The case material will then be sent to another wound, skin, ostomy, or c o n t i n e n c e care clinician, w h o will also address m a n a g e m e n t concerns. Alternative solutions to difficult wound, skin, ostomy, or incontinence clinical situations will be published.
O
PATIENT WITH JEJUNOSTOMY, CAPUT MEDUSAE, AND BLEEDING PERISTOMAL VARICES A 56-year-old woman was admitted from a skilled-nursing facility after numerous episodes of severe bleeding from her jejunostomy stoma. She had shortbowel syndrome and had been receiving total parenteral nutrition for 2 years. After a long history of abdominopelvic endometriosis treated with radiotherapy, adhesions and bowel obstructions developed, necessitating multiple abdominal operations. Ultimately, the patient's bowel from distal jejunum to rectum was resected and a permanent jejunostomy was created. Her course was further complicated by the development of severe cholestatic liver disease related to total parenteral nutrition, jaundice, and portal hypertension. She had chronic abdominal and pelvic pain related to postherpetic neuralgia and used sublingual morphine as needed. The ET nurse was consulted to see the patient. The jejunostomy stoma was noted to be friable, and it bled easily when cleaned. There was peristomal skin erosion from the i to 3 o'clock positions for 0.2 to 0.3 cm. The patient reported that the bleeding started in this area and was stopped only after constant pressure to the site by caregivers. She also stated that the bleeding sites seemed to vary, that the bleeding was happening more frequently, and that she sometimes had to go to the hospital for suturing.
FIGURE 1. Jejunostomy stoma with caput medusae. Actual peristomal color was more bluish than photograph illustrates.
Peristomal varices extended outward for 3 to 4 cm surrounding the stoma. The peristomal skin was observed to have a bluish-pink hue (Figure 1). The appearances of the stoma and the peristomal skin were characteristic of caput medusae, representing a manifestation of the patient's severe liver disease and portal hypertension. The patient was not a candidate for any corrective surgery because of her medical condition, nor would she have been willing to undergo such a procedure. The ET nurse needed to develop a plan of care for the skilled-nursing facilitythat would minimize the episodes of bleeding. She also had to recommend treatment measures that they could initiate should bleeding occur, with the hope of preventing her readmission to the hospital. Maureen Hanlon, RN, MN, CETN: The patient was wearing a transparent one-piece pouch. Bleeding episodes were so profuse, however, that is was impossible to visualize the site of origin of the bleeding, and the pouch had to
Maureen Hanlon, RN, MN, CETN, is an Ostomy/Skin Care Nurse Clinical Specialist at Scott and White Hospital, Temple, Texas. Donna Loehner, RN, BSN, CETN, is an ETnurse practicing the full scope of practice at Lahey Hitchcock Clinic, Burlington, Massachusetts. J WOCN 1997;24:123-125 Copyright © 1997 by the Wound, Ostomy and Continence Nurses Society. 0022-5223/97 $5.00 + 0
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JWOCN March 1997
124 Hanlon and Loehner
FIGURE 2. Two-piece pouching,system over jejunostomy, connected to bedside drainage to keep it empty and help prevent leakage.
be removed each time to apply pressure. This removal delayed treatment and was traumatic to the peristomal skin. The patient was therefore fitted with a two-piece system so that the pouch could be easily snapped off for evaluation and treatment during bleeding episodes. The Durahesive barrier (ConvaTec, Inc., Princeton, N.J.) was chosen because it is soft and does not exert traumatic effects on the mucosa. The barrier's ability to swell and "turtleneck" protected the peristomal skin from the erosive effluent and sealed longer, avoiding the trauma of frequent pouch changes. The barrier was cut slightly larger than the stoma to prevent rubbing against the friable tissue. The patient had copious liquid effluent because she drank frequently. The pouch was connected to a bedside drainage bag to keep it empty and help prevent leakage, which could further erode the peristomal skin and cause the varices to bleed. Tubing from the bedside bag was inserted into the bottom of the pouch. The plastic of the pouch was gathered around the tubing and tied with a rubber band. Waterproof tape was then wrapped around the connection to further secure it (Figure 2). The skillednursing facility staff were instructed to use gentle care and change the pouch
every 4 to 5 days, or as necessary to prevent leakage. If bleeding occurred, staff were instructed to apply firm pressure with two gloved fingers over the identified site of origin. The pouch could be gently unsnapped if necessary to visualize the stoma. If this was ineffective, pressure was to be applied with a gauze pad saturated with a solution of epinephrine (1:100,000), a local vasoconstrictor. If this did not stop the bleeding, a nurse could carefully apply a silver nitrate stick to the bleeding site. A nurse from the patient's skilled-nursing facility was instructed in the correct use of silver nitrate sticks. This topical hemostatic agent must be used with caution to prevent damage to healthy tissue and erosion into deeper blood vessels as a result of excess pressure. This plan of care helped decrease the patient's number of readmissions to the hospital for bleeding peristomal varices. Donna Loehner, RN, BSN, CETN: Patients with peristomal varices have the potential for multiple admissions to the emergency department caused by recurrent peristomal bleeding. My goal for this patient would be to find a pouching system that would contain her stool while minimizing trauma to the peristomal area, thus preventing bleeding. I would also use a two-piece pouching system for this patient. I would not, however, use a Durahesive barrier. Durahesive does not have a floating flange, which is important because it eliminates the need to apply pressure on the peristomal area, which could initiate bleeding. Durahesive is also costly to change every 4 days. The barrier opening should be cut 1/s-inch larger than the stoma to avoid rubbing or trauma to the stoma. I would also cut radial slits in the barrier opening at the 12, 3, 6, and 9 o'clock positions, to prevent the wafer from cutting into the stoma during peristalsis. Because this patient has short-bowel syndrome and the enzyme content of the effluent can quickly melt the barrier, extra protection is needed around the stoma opening. I would use a heavy bead of Stomahesive paste (ConvaTec) to enhance the seal and further protect the peristomal tissue.
JWOCN Volume 24, Number 2
Alternative treatments for bleeding p e r i s t o m a l varices w o u l d include the application of Surgicel (Johnson & Johnson, Arlington Texas) or Gelfoam (Upjohn Company, Kalamazoo, Mich.). Both of these dressings have hemostatic properties and can be held against the site with moderate pressure until bleeding stops. Kaltostat (Dow Hickman, Sugarland, Texas), a calcium alginate dressing, could also be used, because
Hanlon and Loehner 125
the fibers form a meshwork that enhances platelet aggregation and helps control minor bleeding. Silver nitrate sticks could stimulate more bleeding. Medical personnel who use them must be thoroughly educated regarding their correct application and precautions. If conservative measures do not alleviate the recurrent bleeding episodes, sclerotherapy might be considered as a treatment.
Ptions in Practice presents different m a n a g e m e n t a p p r o a c h e s to the same clinical situation.You are invited to submit a brief case description, i n c l u d i n g the specialty nursing c a r e provided, a n d several glossy, color photographs of the clinical situation. The case material will then be sent to another wound, skin, ostomy, or c o n t i n e n c e care clinician, w h o will also address m a n a g e m e n t concerns. Alternative solutions to difficult wound, skin, ostomy, or incontinence clinical situations will be published.
O
PATIENT WITH JEJUNOSTOMY, CAPUT MEDUSAE, AND BLEEDING PERISTOMAL VARICES A 56-year-old woman was admitted from a skilled-nursing facility after numerous episodes of severe bleeding from her jejunostomy stoma. She had shortbowel syndrome and had been receiving total parenteral nutrition for 2 years. After a long history of abdominopelvic endometriosis treated with radiotherapy, adhesions and bowel obstructions developed, necessitating multiple abdominal operations. Ultimately, the patient's bowel from distal jejunum to rectum was resected and a permanent jejunostomy was created. Her course was further complicated by the development of severe cholestatic liver disease related to total parenteral nutrition, jaundice, and portal hypertension. She had chronic abdominal and pelvic pain related to postherpetic neuralgia and used sublingual morphine as needed. The ET nurse was consulted to see the patient. The jejunostomy stoma was noted to be friable, and it bled easily when cleaned. There was peristomal skin erosion from the i to 3 o'clock positions for 0.2 to 0.3 cm. The patient reported that the bleeding started in this area and was stopped only after constant pressure to the site by caregivers. She also stated that the bleeding sites seemed to vary, that the bleeding was happening more frequently, and that she sometimes had to go to the hospital for suturing.
FIGURE 1. Jejunostomy stoma with caput medusae. Actual peristomal color was more bluish than photograph illustrates.
Peristomal varices extended outward for 3 to 4 cm surrounding the stoma. The peristomal skin was observed to have a bluish-pink hue (Figure 1). The appearances of the stoma and the peristomal skin were characteristic of caput medusae, representing a manifestation of the patient's severe liver disease and portal hypertension. The patient was not a candidate for any corrective surgery because of her medical condition, nor would she have been willing to undergo such a procedure. The ET nurse needed to develop a plan of care for the skilled-nursing facilitythat would minimize the episodes of bleeding. She also had to recommend treatment measures that they could initiate should bleeding occur, with the hope of preventing her readmission to the hospital. Maureen Hanlon, RN, MN, CETN: The patient was wearing a transparent one-piece pouch. Bleeding episodes were so profuse, however, that is was impossible to visualize the site of origin of the bleeding, and the pouch had to
Maureen Hanlon, RN, MN, CETN, is an Ostomy/Skin Care Nurse Clinical Specialist at Scott and White Hospital, Temple, Texas. Donna Loehner, RN, BSN, CETN, is an ETnurse practicing the full scope of practice at Lahey Hitchcock Clinic, Burlington, Massachusetts. J WOCN 1997;24:123-125 Copyright © 1997 by the Wound, Ostomy and Continence Nurses Society. 0022-5223/97 $5.00 + 0
21/9/79649
123
JWOCN March 1997
124 Hanlon and Loehner
FIGURE 2. Two-piece pouching,system over jejunostomy, connected to bedside drainage to keep it empty and help prevent leakage.
be removed each time to apply pressure. This removal delayed treatment and was traumatic to the peristomal skin. The patient was therefore fitted with a two-piece system so that the pouch could be easily snapped off for evaluation and treatment during bleeding episodes. The Durahesive barrier (ConvaTec, Inc., Princeton, N.J.) was chosen because it is soft and does not exert traumatic effects on the mucosa. The barrier's ability to swell and "turtleneck" protected the peristomal skin from the erosive effluent and sealed longer, avoiding the trauma of frequent pouch changes. The barrier was cut slightly larger than the stoma to prevent rubbing against the friable tissue. The patient had copious liquid effluent because she drank frequently. The pouch was connected to a bedside drainage bag to keep it empty and help prevent leakage, which could further erode the peristomal skin and cause the varices to bleed. Tubing from the bedside bag was inserted into the bottom of the pouch. The plastic of the pouch was gathered around the tubing and tied with a rubber band. Waterproof tape was then wrapped around the connection to further secure it (Figure 2). The skillednursing facility staff were instructed to use gentle care and change the pouch
every 4 to 5 days, or as necessary to prevent leakage. If bleeding occurred, staff were instructed to apply firm pressure with two gloved fingers over the identified site of origin. The pouch could be gently unsnapped if necessary to visualize the stoma. If this was ineffective, pressure was to be applied with a gauze pad saturated with a solution of epinephrine (1:100,000), a local vasoconstrictor. If this did not stop the bleeding, a nurse could carefully apply a silver nitrate stick to the bleeding site. A nurse from the patient's skilled-nursing facility was instructed in the correct use of silver nitrate sticks. This topical hemostatic agent must be used with caution to prevent damage to healthy tissue and erosion into deeper blood vessels as a result of excess pressure. This plan of care helped decrease the patient's number of readmissions to the hospital for bleeding peristomal varices. Donna Loehner, RN, BSN, CETN: Patients with peristomal varices have the potential for multiple admissions to the emergency department caused by recurrent peristomal bleeding. My goal for this patient would be to find a pouching system that would contain her stool while minimizing trauma to the peristomal area, thus preventing bleeding. I would also use a two-piece pouching system for this patient. I would not, however, use a Durahesive barrier. Durahesive does not have a floating flange, which is important because it eliminates the need to apply pressure on the peristomal area, which could initiate bleeding. Durahesive is also costly to change every 4 days. The barrier opening should be cut 1/s-inch larger than the stoma to avoid rubbing or trauma to the stoma. I would also cut radial slits in the barrier opening at the 12, 3, 6, and 9 o'clock positions, to prevent the wafer from cutting into the stoma during peristalsis. Because this patient has short-bowel syndrome and the enzyme content of the effluent can quickly melt the barrier, extra protection is needed around the stoma opening. I would use a heavy bead of Stomahesive paste (ConvaTec) to enhance the seal and further protect the peristomal tissue.
JWOCN Volume 24, Number 2
Alternative treatments for bleeding p e r i s t o m a l varices w o u l d include the application of Surgicel (Johnson & Johnson, Arlington Texas) or Gelfoam (Upjohn Company, Kalamazoo, Mich.). Both of these dressings have hemostatic properties and can be held against the site with moderate pressure until bleeding stops. Kaltostat (Dow Hickman, Sugarland, Texas), a calcium alginate dressing, could also be used, because
Hanlon and Loehner 125
the fibers form a meshwork that enhances platelet aggregation and helps control minor bleeding. Silver nitrate sticks could stimulate more bleeding. Medical personnel who use them must be thoroughly educated regarding their correct application and precautions. If conservative measures do not alleviate the recurrent bleeding episodes, sclerotherapy might be considered as a treatment.