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What if you get bleeding on or around your stoma?

When your stoma was formed, a piece of bowel was brought out onto the surface of your tummy through your abdominal wall. This piece of bowel was then folded back upon itself to form your stoma, rather like when you turn over the cuff of your jumper, so the inner surface or lining of your bowel is now on the outside. This inner surface has lots of superficial blood vessels which can bleed easily, because of this a small amount of bleeding when cleaning around your stoma is normal.

What can cause bleeding on or around your stoma?

• Trauma, often the result of over diligent cleaning techniques
• Friction
• Clips or stitches around your stoma
• Ulcers
• Granulomas*
• A ruptured blood vessel.

*Granulomas are warty growths around the base of your stoma. They probably occur as a reaction to the continual friction from your stoma pouch. Granulomas are harmless but can be tender. Their persistent bleeding can sometimes hinder the application and adhesion of your pouch.

Hints and tips

• Remember, gently does it. Soft cleaning wipes and warm water are all you need to clean around your stoma
• The use of OstoZYME odour neutralising pouch lubricant on the inside of your pouch can help to prevent friction
• Sometimes ulcers on your stoma can occur when you have been poorly or stressed and will usually clear up as your health improves
• Make sure that you have at least a 1mm clearance between your stoma and the pouch to prevent friction occurring
• You may wish to apply a thin layer of stoma paste, a stoma seal or a collar around the base of your stoma for added protection
• Apply cold pressure. A small bag of ice is ideal if you have a specific bleeding point on your stoma. Seek urgent medical advice if this does not stop the bleeding.

See your doctor or stoma care nurse for advice regarding:

• Treatment of granulomas, a ruptured blood vessel or ulcers on your stoma
• Excessive bleeding
• Blood coming from the inside of your stoma where your waste normally comes from.

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What is bowel leakage or incontinence?

Bowel leakage or incontinence is caused by the loss of regular control of the bowels causing involuntary leakage to occur.

What can cause bowel leakage or incontinence?

• Surgery which involves removing a part of the bowel
• Surgery can affect the normal working pattern of the bowel
• Surgery can also affect the sensitivity of the nerve endings in the back passage that tell you whether it is wind or stool waiting to come out
• Very rarely there can be some damage to the muscle which forms the entry into your back passage
• Diarrhoea or loose stool, which is more difficult to control
• Some foods or medicines affect how loose or firm your stool is.

Hints and tips

The following exercises may help you to retrain your bowel control:

• If you feel any pressure or filling sensation in your back passage try not to panic. Tensing all your muscles, holding your breath or rushing to the lavatory can make things worse. Instead sit or stand still, breathe deeply and tighten the muscles (sphincter muscles) around your back passage until the urge passes
• Imagine that your sphincter muscle is a lift. When you squeeze as tightly as you can, your lift goes up to the fourth floor. It will not stay there very long because it has used up all its energy getting there. Likewise, squeezing as tightly as you can won’t get you safely to the lavatory because the muscle will get tired very quickly. So now squeeze more gently and take your lift only up to the second floor. Feel how much longer you hold it at that level. You may not be able to do this at first so practice the exercise at times when you do not want to empty your bowels
• Sit on the lavatory and hold on for as long as you can before opening your bowels. Don’t worry if you can only manage a few seconds, it will become easier with practice. Try to relax and concentrate on breathing very calmly. It may be helpful to take something to read
• Once you can delay opening your bowels for a few minutes, the unpleasant urge to go will improve. Get up and leave the lavatory. Return a few minutes later when there is no urge and try to open your bowels
• The longer you can hold on, the more fluid is absorbed from the stool, and firmer stools can help to reduce urgency.

The following exercises may help to strengthen your sphincter muscles:

• Sit, stand or lie with your knees slightly apart and imagine that you are trying to stop yourself passing wind. To do this you must squeeze the muscles around your back passage. Try squeezing and lifting the muscles as tightly as you can as if you are really worried that you are about to leak. You should be able to feel the muscles move. Your buttocks, tummy and legs should not move much at all. You should be aware of the skin around your back passage tightening and being pulled up and away from your chair. You should not need to hold your breath when you tighten these muscles
• Tighten and pull up the sphincter muscles as tightly as you can. Hold on for at least five seconds and then relax for at least ten seconds. Repeat at least five times. This will work on the strength of your muscles
• Pull the muscles up to about half of their maximum squeeze. See how long you can hold this. Then relax for at least ten seconds. Repeat at least five times. This will work on the endurance or staying power of your muscles
• Pull up the muscles as quickly and tightly as you can, relax, then pull up again. See how many times you can do this before you get tired. Try for at least five minutes.

Do these exercises at least ten times every day. Your control and confidence will gradually improve. You may need to do these exercises regularly for several months before the muscles gain their full strength and you regain regular bowel control. If necessary, a referral to a continence advisor can be made. He or she has specialist knowledge in helping people overcome problems with bowel control.

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What is dehydration?

Dehydration occurs when you pass more fluids out of your body than you take in.

What can cause dehydration?

• An acute bout of diarrhoea caused by a tummy bug or food poisoning
• Drinking too much alcohol
• Hot and humid conditions which cause us to perspire more freely.

What are the signs you should be aware of?

• An increased watery output from your stoma
• A decrease in the amount of urine you pass
• Very dark coloured urine
• Hangover like symptoms such as headache, dry mouth, increased thirst, feeling light headed or dizziness
• Any combination of the above symptoms.

Hints and tips

• Drink 1 litre of rehydration solution over 24 hours. Rehydration solutions are Dioralyte or Rehydrate powder dissolved in 1 litre of water in 24 hours. These are available from your pharmacy
• Drink Isotonic ‘sport’ drinks – 1 litre in 24 hours. If you are a diabetic use only the rehydration solutions from the pharmacist
• Take an extra teaspoon of salt in 24 hours. This can be achieved by putting more salt directly onto your food, or by adding extra salt to your cooking
• Bovril or Marmite can be made into a drink or spread on toast/bread
• Eat salted crisps or crackers with added salt such as Ritz
• Remember to continue to drink your normal daily amount of water, squash, fruit juices etc in addition to the rehydration solutions. However you may wish to cut down on tea & coffee as both these can increase dehydration
• Try not to eat & drink at the same time
• If you have been prescribed anti diarrhea medication remember to take it 45-60 minutes BEFORE food
• Inform your doctor if tablets or capsules are passing straight through into your pouch. Most anti diarrhea medicines are available in liquid form
• If you have any of the above symptoms and are feeling unwell, it is important to speak to your doctor or stoma care nurse without delay.

The following recipe for The World Health Organisation Oral Rehydration Solution can be made up in your own home:

• 1/3-2/3 of a teaspoon of salt
• 3/4 of a teaspoon of bicarbonate of soda
• Juice of 1/2 an orange
• 3 & 1/3 tablespoons of sugar
• 1 litre (1 & 3/4 pints or 35 fluid ounces) of boiled or sterile water.

Make up a fresh solution daily & discard any left after 24 hours.

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What is an ileostomy blockage or obstruction?

This is a blocked or obstructed portion of your bowel which prevents your stoma functioning normally.

What causes a blockage or obstruction?

• A lump of undigested food that blocks ileostomy. This type of blockage is normally relieved by the sudden and often explosive passage of that lump of food
• Adhesions. These are internal bands of scar tissue which can sometimes cause internal organs to stick together. Adhesions can kink, twist or pull the bowel causing an obstruction.

Signs and symptoms of a blockage or obstruction

• Bloated and/or swollen tummy
• Abdominal pain and/or cramp
• Nausea and/or vomiting
• No waste from your stoma
• Watery output from your stoma
• Swollen stoma
• Signs of dehydration.

What to do if you develop signs and symptoms of a blockage or obstruction

• Stop eating solid food
• Increase your intake of fluids. Drink cola or sports drinks as well as water
• If your stoma is swollen, remove your pouch and replace it with one with a larger opening
• Massage your tummy and try to relax
• Soak in a warm bath. This will relax your abdominal muscles and may relieve the blockage by allowing the passage of an undigested lump of food
• Do not wait too long to speak to your doctor or stoma care nurse
• Do not take a laxative
• Do not insert anything into your stoma unless instructed to do so and under the supervision of a health care professional
• Do not eat or drink if you are vomiting, not passing anything from your stoma or both of these.

Hints and tips

• Take time to chew your food properly
• Some foods are more likely to cause problems than others, you may want to limit or avoid these.

It is important to speak to your doctor or stoma care nurse if your symptoms persist for over 8 hours, OR if you have symptoms of dehydration such as dry mouth, headache, dark concentrated urine or a decrease in the amount of urine passed. Hospital admission may be required.

Foods that may cause blockage or obstruction

• Sweetcorn, nuts and seeds
• High fibre vegetables and the pith of citrus fruit
• Dried fruit or vegetables, coconut, popcorn
• Mushrooms, onions
• Bean sprouts, bamboo shoots
• Celery, peppers, lettuce
• Asparagus, pineapple, melon
• Tomato or fruit skin.

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What is odour?

Stools have an odour that can vary depending on what we eat or drink. This does not change when you have a stoma. Your stoma pouch is made from special laminated and odour proof plastic. When it is in place and properly applied, there should not be an odour.

What can cause odour?

• • Pouch management
  • Pouch leakage
  • Leakage from pouch filter
  • Dietary intake.

Hints and tips

• Spray the room with an odour neutralising deodorant spray before and after each pouch change
• If you use a drainable pouch, follow the same routine as above when emptying it
• Add 1 or 2 drops of OstoMIST odour neutralising drops directly into your clean pouch before application
• Strike a match and blow it out straight away, the sulphur tip of the match will help to reduce or eliminate odour
• Pouch leakage either from around the pouch seal or from underneath the adhesive will cause odour. If this happens, change your pouch as soon as possible
• Stoma shrinkage and skin creases can occur and this may require a reassessment of your pouch and its fitting
• Eating bio or live yoghurt can help to neutralise odour
• Drinking buttermilk may help to reduce odour
• If odour is escaping through the pouch filter, you may want to cover the filter with one of the adhesive tabs supplied with the box of pouches.

The foods listed below may increase the odour from your stoma output. However, this will only be noticeable when you empty or change your pouch, or if you have leakage problems. You may want to avoid the foods that affect you.

• Green vegetables
• Onions
• Garlic
• Eggs
• Fish
• Cheese
• Cucumber
• Asparagus.

Remember, different foods and drinks affect everyone in different ways. Deciding on what best suits your own particular needs is often a case of ‘try it and see’. If odour leakage from your stoma pouch is a recurrent problem then contact your stoma care nurse for advice

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What is a parastomal hernia?

A parastomal hernia is a bulge or swelling around or underneath your stoma. The hernia usually develops slowly and may increase in size over time.

What can cause a parastomal hernia?

When a stoma is created, the end of the bowel is brought out onto your tummy through the muscle of the abdominal wall. This process can cause a weakness or gap in the abdominal muscle. Sometimes a loop of bowel bulges through that gap causing a hernia to develop.

Hints and tips

In the weeks following your stoma surgery:

Getting back to your normal lifestyle:

• Try not to gain weight, or lose a bit of weight if you need to
• Always check with your doctor or stoma nurse before starting any new exercise programme or sport.

It is important to remember that:

• Not everyone gets a parastomal hernia, nor do all hernias cause pain, symptoms or stoma management problems
• Most parastomal hernias can be managed using an abdominal support garment
• If your parastomal hernia does increase in size, it can make pouch choice and fitting difficult
• Surgery to repair a parastomal hernia is always the last resort as there is a very high risk that the hernia will recur
• A strangulated hernia is a rare complication. If this happens, you will experience severe pain in your tummy, your stoma will stop working and will change from its normal bright red colour to a darker, bluish red. Seek help immediately as you will require urgent surgical treatment.

If you need advice or help about pouch management or the use of support garments, make an appointment to see your stoma care nurse.

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What is rectal discharge?

If you have had an operation resulting in the formation of a stoma, but have not had your rectum removed you may get a discharge from your back passage which is normal. The rectum produces a natural lubricating substance called mucus which is discharged through your back passage.

What causes rectal discharge?

Although bowel waste no longer goes through your back passage, it is normal for the lining of the rectum to continue to produce and discharge mucus. The amount of mucus produced varies from person to person. Mucus is clear or putty coloured, although initially it may contain stool debris which stains it brown. Sometimes the mucus is sticky or thick and may be uncomfortable. It can also irritate the skin around your back passage.

Hints and tips

• To evacuate the mucus, sit on the lavatory and gently bear down as if you were having your bowels opened. Do not strain
• If the mucus won’t come away naturally, it can build up in your back passage and become uncomfortable. If this happens, a glycerine suppository inserted into the back passage may be advised by your doctor
• Mucus leakage or discharge may cause the skin around your back passage to get sore. Regular gentle washing and drying of the area will help to prevent soreness
• Using a barrier cream or barrier film such as OstoGUARD or an appropriate alternative can help to protect and soothe your skin
• Wear a disposable pad or panty liner, which will help to absorb the discharge
• Some people have reported that they notice an increase in mucus secretion after eating certain foods. If you think there could be a connection, keep a food diary to try to identify the source
• Mucus leakage and discharge may decrease with time
• Contact your doctor or stoma care nurse if the mucus discharge becomes yellowish green or contains blood.

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What is sore skin?

The skin around your stoma called the peristomal skin can become red but intact, sore but dry or broken and wet.

What causes red or sore skin?

• Waste from your stoma getting directly on to your skin
• Changing your stoma pouch too frequently causing trauma to your skin
• Sensitivity or allergies
• Pre-existing skin conditions.

Hints and tips

• Some redness is to be expected when you change your pouch. Pulling the adhesive off your skin makes it react in this way
• Be gentle when removing your pouch. Using an adhesive remover such as OstoCLEAR can help
• Shaving your peristomal skin may be necessary if body hair is an issue. Trauma caused by the pouch adhesive ripping the hair off your body can give you inflammation of the hair follicle or root (folliculitis). If using a razor, take care not to cut your stoma & only use the razor blade once before discarding it. You may prefer to use an electric razor
• Use a skin barrier film such as OstoGUARD or a suitable alternative before putting on a new pouch. This will protect your skin and also help to reduce redness when you remove your pouch
• The flange part of your pouch needs to fit snugly around your stoma with no more than a 1mm gap between the stoma and flange. If the gap is too large your skin will be exposed to the pouch content resulting in sore skin
• If the flange is cut too small, the adhesive will rest on your stoma instead of on your skin and the risk of waste getting underneath the flange and onto your skin is increased
• For broken skin a barrier cream such as OstoGUARD, or a specially formulated protective powder such as OstoSEAL can help
• If you are using a 1-piece pouch, you may wish to consider using a 2-piece system until your sore skin has healed.

Pre-existing skin conditions

If you already suffer with skin problems such as psoriasis, eczema, sensitivity or allergies, you could be more at risk of these conditions developing around your stoma. Different skin conditions present in different ways so a medical or nursing assessment is essential. Make an appointment to see your doctor or stoma care nurse to discuss any peristomal skin problem, which may be worrying you. They will offer you the appropriate advice and treatment to deal with the situation.

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What is wind?

Wind or flatulence is the release of intestinal gas through your stoma.

What can cause wind?

• Swallowing air whilst eating or talking
• Fermentation of food by bacteria, a natural process of digestion
• Some food and drinks
• Chewing gum
• Some laxatives
• Long periods without food
• Smoking.
• Eat regularly
• Don’t eat and drink at the same time
• Don’t talk and eat at the same time
• Try not to smoke
• Don’t chew gum
• Sit down to enjoy your food in a relaxed and calm environment
• Try not to eat large meals late in the evening.

• Green beans, broccoli, cabbage, spinach, sprouts
• Parsnips, turnips
• Baked beans, peas, sweetcorn
• Onions, garlic, mushrooms, cucumber
• Some fresh or dried fruits such as banana, apricots etc.
• Eggs
• Spicy foods
• Foods high in insoluble fibre
• Grains
• Fizzy drinks, beer and lager.

Introduce any of these foods and drinks into your diet gradually. Not everything listed will cause you to have wind problems. Keep a food diary to identify the foods or drinks that could be causing you to have an increased amount of wind.

The food and drink listed below can help you avoid wind.

• Peppermint tea or peppermint oil in hot water
• Fennel to eat or drink
• Cinnamon to eat or drink (but not if you are pregnant)
• Probiotic yogurts or drinks
• Always drink plenty of water.

If you have been prescribed laxatives do not stop taking them without first discussing it with your doctor or stoma care nurse.