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 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 ... 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... 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