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The triad of colostomy care
The
Triad
of Colostomy
Care
DUKAND BENJAMIN, M.D., St. Louis, 34issouri Fmm the Deportments of Surgery, St. Louis University School qf Medicine, and St. Antbony’s Hospital, St. Louis, MO.
THE proper care of the colostomy has Iong been a subject of suggestions, articles and papers. This is simply an expression of the unsatisfactory answer for this probIem. The fear of the average patient who is required to undergo an operative procedure which necessitates a COIOStomy as the end result of that procedure, is almost invariably the dread of the patient’s social acceptabihty among his fellows. It has been recognized for many years that adequate, complete cIeansing of the colon at regular intervals wiI1 permit these patients to enjoy a comfortab1e life, free of embarrassment, and permit them to mingle with other peopIe with complete confidence that no fecal accident will mar that association with others. The triad of co1ostomy care is made up of three requisites: (I) consistency of the feca1 stream; (2) contro1 of peristaIsis; and (3) complete or adequate cIeansing of the large bowel. The first two portions of this triad are fairI)easily solved. The diet of the colostomy patient should consist of simple, bland foods which in themsetves do not promote hyperperistaIsis, and the strict avoidance of any foods which promote hyperperistalsis or to which the patient exhibits any allergic tendencies. The dietary regimen as suggested by the Massachusetts General HospitaI has proved to be a most satisfactory type of diet. The patient is started out on a limited diet to begin with which consists of boiled milk with cream of wheat and sugar, hard boiled eggs, dry toast, and a rather restricted amount of fluids for breakfast. Lunch consists of creamed soups, fish or meat with baked or mashed potatoes and boiled rice or custards. Dinner consists of meat or fish creamed and the avoidance of spinach or carrots in their vegetab1e.s. Later the diet may be liberalized and eventuaIIy the patients are able to determine for themseIves what foods shouId be avoided in order to maintain a semi-soIid satisfactory type of stoo1. 127
The second portion of the triad consists of the control of peristaIsis or perhaps it may be better stated, the inhibition or slowing of peristalsis. The diminution of perista1sis and the avoidance of hyperperistaIsis may be easil! accomp1ished by the use of any of the antrcholinergic drugs. I had long been impressed by the fact that patients on reducing diets who sulfate or were given dextro-amphetamine racemic amphetamine suIfate consistent1y compIained of constipation. These drugs abolish or diminish hunger by their antiperistaltic action which also results in constipation in these patients. It impressed me that this constipating action which is an undesirabIe side effect in the weight reduction patient shouId prove to be a most desirable type of primary effect in the coIostomy patient. It aIso occurred to me that in order to avoid the appetite suppressing effect of the drug, one couid give it after meals, and thereby produce the constipating action as a primary effect without the anorexia. This proved to be the case, and I found that the bowe1 movements of these patients were satisfactoriIy controIIed. A further desirable effect of the drug was the sense of alertness and wellbeing these patients noted while taking the drug. With two of the three requisites accomplished, there remained onIy the satisfactor? cIeansing of the Iarge bowe1 to make the triad complete. I have read for a number of years the papers and articles dealing with the satisfactory cleansing of the bowel and noted that all these devices had as their objective the preventing of the soiling of the patient during the period of administering the enema. If one is to accomplish compIete cIeansing of the bowel, it is necessary for this cleansing effect to reach back to and include the cecum. This is an impossibiIity unIess a closed system is maintained whiIe administering the enema. While watching one of my uroIogy coIIeagues inserting a hemostatic bag catheter caIIed the Foley catheter, it occurred to me that this should be an idea1 type of instrument to use in
PracticaI
SurgicaI
the administration of the enema. Subsequent testing has proved the thought to be correct. The patient inserts a No. 24 FoIey catheter with a 30 cc. bag through the colostomy stoma and then injects 30 cc. of air through the tube Ieading to the bag, using an ordinary longtipped Asepto syringe. The tube is clamped with the fingers, the syringe is removed and an ordinary wood goIf tee is inserted to prevent the loss of air in the bag. The patient is then ready to administer the enema. The tip of the tubing leading from the enema container is fitted with a glass tube which is inserted into the catheter portion of the Foley catheter. SIight backward puI1 is made on the FoIey catheter which effectuaIIy brings the bag against the posterior part of the abdominal
Suggestions waI1 and the enema may be administered without the sIightest suggestion of Ieakage. After the administration of the enema the tube is heid with the fingers and the enema tip removed. The patient either bends over the toilet bow1 or hoIds a basin under the stoma. The air is aIIowed to escape from the bag of the catheter by removing the wood golf tee and the catheter is then drawn from the stoma. The colonic content is aIIowed to escape. There is no unpleasantness or soilage and I have been impressed by the fact that these patients have been most happy and contented under this regimen. I find that most of my patients are able to cIeanse the bowe1 in this manner, once in forty-eight hours as Iong as they watch their diet and use the amphetamine sulfate.
X-RAY therapy for cancer of the cervix uteri occasionaIIy produces serious gastrointestina1 complications. Some patients have cIinica1 evidence of injury to the rectosigmoid and these patients have bIoody stooIs, diarrhea and tenesmus. When the iIeum is damaged, signs of smaI1 bowe1 obstruction may be present. X-rays can produce ulcers of the mucosa, resulting in perforation, peritonitis and death. Moreover, these mucosa1 uIcers hea sIowIy with excessive scar tissue and adhesions, often causing intestina1 stenosis and obstruction. (Richard A. Leonardo, M.D.)
128
Triad
of Colostomy
Care
DUKAND BENJAMIN, M.D., St. Louis, 34issouri Fmm the Deportments of Surgery, St. Louis University School qf Medicine, and St. Antbony’s Hospital, St. Louis, MO.
THE proper care of the colostomy has Iong been a subject of suggestions, articles and papers. This is simply an expression of the unsatisfactory answer for this probIem. The fear of the average patient who is required to undergo an operative procedure which necessitates a COIOStomy as the end result of that procedure, is almost invariably the dread of the patient’s social acceptabihty among his fellows. It has been recognized for many years that adequate, complete cIeansing of the colon at regular intervals wiI1 permit these patients to enjoy a comfortab1e life, free of embarrassment, and permit them to mingle with other peopIe with complete confidence that no fecal accident will mar that association with others. The triad of co1ostomy care is made up of three requisites: (I) consistency of the feca1 stream; (2) contro1 of peristaIsis; and (3) complete or adequate cIeansing of the large bowel. The first two portions of this triad are fairI)easily solved. The diet of the colostomy patient should consist of simple, bland foods which in themsetves do not promote hyperperistaIsis, and the strict avoidance of any foods which promote hyperperistalsis or to which the patient exhibits any allergic tendencies. The dietary regimen as suggested by the Massachusetts General HospitaI has proved to be a most satisfactory type of diet. The patient is started out on a limited diet to begin with which consists of boiled milk with cream of wheat and sugar, hard boiled eggs, dry toast, and a rather restricted amount of fluids for breakfast. Lunch consists of creamed soups, fish or meat with baked or mashed potatoes and boiled rice or custards. Dinner consists of meat or fish creamed and the avoidance of spinach or carrots in their vegetab1e.s. Later the diet may be liberalized and eventuaIIy the patients are able to determine for themseIves what foods shouId be avoided in order to maintain a semi-soIid satisfactory type of stoo1. 127
The second portion of the triad consists of the control of peristaIsis or perhaps it may be better stated, the inhibition or slowing of peristalsis. The diminution of perista1sis and the avoidance of hyperperistaIsis may be easil! accomp1ished by the use of any of the antrcholinergic drugs. I had long been impressed by the fact that patients on reducing diets who sulfate or were given dextro-amphetamine racemic amphetamine suIfate consistent1y compIained of constipation. These drugs abolish or diminish hunger by their antiperistaltic action which also results in constipation in these patients. It impressed me that this constipating action which is an undesirabIe side effect in the weight reduction patient shouId prove to be a most desirable type of primary effect in the coIostomy patient. It aIso occurred to me that in order to avoid the appetite suppressing effect of the drug, one couid give it after meals, and thereby produce the constipating action as a primary effect without the anorexia. This proved to be the case, and I found that the bowe1 movements of these patients were satisfactoriIy controIIed. A further desirable effect of the drug was the sense of alertness and wellbeing these patients noted while taking the drug. With two of the three requisites accomplished, there remained onIy the satisfactor? cIeansing of the Iarge bowe1 to make the triad complete. I have read for a number of years the papers and articles dealing with the satisfactory cleansing of the bowel and noted that all these devices had as their objective the preventing of the soiling of the patient during the period of administering the enema. If one is to accomplish compIete cIeansing of the bowel, it is necessary for this cleansing effect to reach back to and include the cecum. This is an impossibiIity unIess a closed system is maintained whiIe administering the enema. While watching one of my uroIogy coIIeagues inserting a hemostatic bag catheter caIIed the Foley catheter, it occurred to me that this should be an idea1 type of instrument to use in
PracticaI
SurgicaI
the administration of the enema. Subsequent testing has proved the thought to be correct. The patient inserts a No. 24 FoIey catheter with a 30 cc. bag through the colostomy stoma and then injects 30 cc. of air through the tube Ieading to the bag, using an ordinary longtipped Asepto syringe. The tube is clamped with the fingers, the syringe is removed and an ordinary wood goIf tee is inserted to prevent the loss of air in the bag. The patient is then ready to administer the enema. The tip of the tubing leading from the enema container is fitted with a glass tube which is inserted into the catheter portion of the Foley catheter. SIight backward puI1 is made on the FoIey catheter which effectuaIIy brings the bag against the posterior part of the abdominal
Suggestions waI1 and the enema may be administered without the sIightest suggestion of Ieakage. After the administration of the enema the tube is heid with the fingers and the enema tip removed. The patient either bends over the toilet bow1 or hoIds a basin under the stoma. The air is aIIowed to escape from the bag of the catheter by removing the wood golf tee and the catheter is then drawn from the stoma. The colonic content is aIIowed to escape. There is no unpleasantness or soilage and I have been impressed by the fact that these patients have been most happy and contented under this regimen. I find that most of my patients are able to cIeanse the bowe1 in this manner, once in forty-eight hours as Iong as they watch their diet and use the amphetamine sulfate.
X-RAY therapy for cancer of the cervix uteri occasionaIIy produces serious gastrointestina1 complications. Some patients have cIinica1 evidence of injury to the rectosigmoid and these patients have bIoody stooIs, diarrhea and tenesmus. When the iIeum is damaged, signs of smaI1 bowe1 obstruction may be present. X-rays can produce ulcers of the mucosa, resulting in perforation, peritonitis and death. Moreover, these mucosa1 uIcers hea sIowIy with excessive scar tissue and adhesions, often causing intestina1 stenosis and obstruction. (Richard A. Leonardo, M.D.)
128