Fistula Care--Not Just Containment of Effluent

Ms. R (name changed for anonymity), a vibrant, active, happily married 29 year old, developed her first small bowel obstruction around June, 2007, which was successfully managed conservatively.  Her second obstruction presented in April, 2008, with surgical intervention followed by 3 more surgeries in about 3 days.  This was not her first time for surgeries to her abdomen…when she was an infant, she had omphalocele resulting in six abdominal surgeries before her sixth birthday.

Following her surgeries in April, she developed a small bowel fistula which developed a pseudostoma in a matter of days.  Unsuccessful attempts to close it were made, and she subsequently went home with a wound pouching system, PICC line and TPN.  When she presented to our facility, her fistula pseudostoma had developed fully into a loop ileostomy AND prolapsed—measuring:  16cm long and 5cm in diameter.  Her skin was grossly denuded requiring immediate attention.  She was unable to look at the stoma, let alone touch it.  Multiple products were utilized for pouching, and a pouch wear time of 7 days was achieved.  Pictures are dramatic when showing the stomal reduction, skin care, pouch placement.  Upon standing the stoma is seen prolapsing instantly.                 

Ms. R was emotionally challenging as she worried about everything!  Her concerns ranged from:  pouch leakage, PICC line replacements, having sex, having children, body image, exercising, etc.  Her family were most supportive during all of this.  Many hours of counseling in the office and over the phone occurred.  Prior to her fistula closure on September 11, 2008, she changed the pouch herself…reducing the prolapse to fit the barrier properly.  She also became secure enough to approach her husband to resume sexual relations.