Stomas of the Small and Large Intestine: Introduction
The use and management of GI stomas in children have
evolved since the early success with colostomy formation in
the 1800s. Improved surgical techniques, better
understanding of the physiologic and psychological
consequences of intestinal stomas, and advances in stoma
care have contributed to more rational use of ostomies by
pediatric surgeons and a wider acceptance in the medical and
lay communities. Nevertheless, treating a child with multiple
abdominal stomas can be intimidating and challenging (see
the image below), especially when the anatomy is not clear
and the fluid and electrolyte abnormalities are difficult to
control.
Multiple stomas in the abdomen of a 3-year-old child who
underwent surgery as an infant for high imperforate anus. A
divided colostomy was performed to divert the stool. The
other end was brought out through the skin (mucous fistula)
to allow evacuation of mucus and gas. A vesicostomy was
performed because of a neurogenic bladder.
Several differences between adult and pediatric ostomies are
recognized. Most stomas in adults are formed in the distal
ileum or colon for the treatment of inflammatory bowel
disease, malignant conditions, and trauma; more proximal
stomas are only rarely created. In contrast, stomas in infants
and children may be required anywhere along the GI tract
because of the wide variety of congenital and acquired
conditions that require stoma formation. The effect of a
stoma on physical and emotional development and on
growth is an additional consideration in children.
Although great advances have been made with regard to
stoma formation and management, both early and late
complications are common. Fortunately, most pediatric
stomas are temporary, and many of the complications
associated with intestinal stomas are eliminated when the
stoma is closed. Understanding enterostomal construction
and physiology is essential for providing these children with
optimal care.
History of the Procedure
Colostomies were used in the late 1800s to treat intestinal
obstruction. Some of the earliest survivors were children with
an imperforate anus. Intestinal stomas were considered a
drastic procedure and were avoided because of the high
incidence of complications and mortality. With
improvements in surgical technique and practice, the need
for stomas increased as children with formerly fatal
conditions survived.
Problem
Pediatric ostomies include any surgically created opening
between a hollow organ and the skin connected either
directly (stoma) or with the use of a tube. In infants and
children, stomas are used for various purposes, including
access, decompression, diversion, and evacuation. As a rule,
most ostomies are for temporary use and are typically
reversible in children. Certain medical conditions may dictate
the need for a permanent stoma.
Frequency
The frequency of intestinal stomas is difficult to determine in
the pediatric population.
Etiology
Many diseases may require a stoma or placement of a tube
within the bowel. Small bowel stomas are used for patients
with intestinal perforation or ischemia in whom an
anastomosis is considered unsafe. A proximal ileostomy is
often used to protect the distal anastomosis after restorative
proctocolectomy for familial polyposis or ulcerative colitis.
Similarly, colostomy is often used both before and after a
pull-through procedure for imperforate anus or Hirschsprung
disease, although many surgeons are now performing
primary pull-through procedures without colostomy for both
of these conditions. Tube cecostomy or Malone
appendicocecostomy have been used for antegrade bowel
irrigation in children with intractable constipation and
various medical conditions.
Children with severe perineal burns or trauma (see the image
below) often require a temporary colostomy to allow the
injury to heal.
Severe injury to the perineum and anal sphincter (caused by
a lawn mower) in a 9-year-old boy. A diverting colostomy
was performed. Several weeks later, a skin graft was placed
over the defect. After reconstruction of the anal sphincter,
the colostomy was reversed.
Patients with the following conditions may require a stoma:
1. Neonatal conditions
 Necrotizing enterocolitis
 Hirschsprung disease
 Meconium ileus
 Imperforate anus
 Complex hindgut anomalies
 Intestinal malrotation
 Intestinal volvulus
 Intestinal atresia, stenosis, and webs

Esophageal atresia with or without tracheoesophageal
fistula
 Trauma
2. Childhood and adolescent conditions
 Trauma
 Inflammatory bowel disease
 Intestinal malrotation
 Intestinal volvulus
 Gardner syndrome and other intestinal polyposis
syndromes
 Typhlitis
 Intestinal pseudo-obstruction
Pathophysiology
The pathophysiologic features depend on the specific disease
process.
Presentation
The clinical presentation depends on the specific diagnosis
and age of the patient.
Indications
For an end stoma (see the images below), the bowel is
divided, and the proximal end is brought through the
abdominal wall. The distal nonfunctioning limb can be
brought out through the same abdominal wall opening as the
end stoma (ie, double-barrel stoma), it can be brought out
through a separate incision (ie, mucous fistula), or it can be
closed and left in the peritoneal cavity (ie, Hartmann
procedure). When the distal segment is left inside the
abdomen, many surgeons fasten it to the abdominal wall
adjacent to the end ostomy or tag it with a nonabsorbable
suture to facilitate identification when the stoma is reversed.
A loop stoma is created by maturing a segment of bowel over
a rod or tube without completely dividing the bowel.
Stomas are used in situations in which diversion of,
decompression of, or access to the bowel lumen is needed.
Relevant Anatomy
The clinical scenario and relevant anatomy may affect the
technique used for stoma creation and the location of the
stoma.
Technique
Several types of intestinal stomas are recognized (see the
image below). The clinical scenario often dictates the
segment of intestine selected, the type of stoma created, and
its external location. In children, most stomas are created as
an end or loop ostomy; however, be familiar with the many
potential variations in their construction. Roux-en-Y
construction can also be performed for tube stomas such as
feeding jejunostomy.
Diagrams illustrate pediatric stomas. (A) End stoma (inset
shows everting maturation); (B) double-barrel stoma: End
stoma and mucous fistula are divided and brought through
the same incision (inset shows closed mucus fistula sutured
to abdominal wall); (C) end stoma with mucous fistula
brought out separate incision; (D) end ileostomy with closed
mucous fistula left inside abdominal cavity; (E) loop stoma;
and (F) decompressing blowhole stoma
Divided end ileostomy and
ileal mucous fistula. The
ileostomy is brought out
through a separate skin
incision.
End ileostomy with closed
distal limb (also known as
Hartman pouch).
End ileostomy with closed
distal intestine after
multiple resections. The
segment without function is
left in situ, and a stoma is
used for decompression.
Loop stomas provide excellent decompression and have the
advantage of simple closure without the need for a separate
laparotomy in most cases. However, loop stomas are not
completely diverting because proximal contents can spill over
into the distal limb. Therefore, they should be used with
caution in patients in whom stool in the distal bowel may be
problematic. A decompressing stoma, or blowhole, is created
in patients in unstable condition by opening the
antimesenteric border of bowel without mobilizing the entire
loop of bowel.
Stomas can also be formed in association with an
anastomosis for proximal or distal venting or irrigation (ie,
Bishop-Koop1 and Santulli stomas [see the images below).
These stomas were initially designed for the treatment of
infants with meconium ileus but have been adapted for many
other purposes. In children with necrotizing enterocolitis,
multiple intestinal atresia, or midgut volvulus in which
multiple bowel anastomoses may be unsafe and in whom
preservation of intestinal length is desired, one or more
discontinuous segments of bowel may be externalized. The
operating surgeon should clearly describe the anatomic
configuration in the surgical notes and provide an illustration
in the patient's chart.
End-to-side
anastomosis created
in an infant with a
complicated
meconium ileus, with
distal stoma used for
irrigation (also
known as the
Bishop-Koop
ileostomy).
In general, a stoma is easier to manage when it is not flush
with the skin. Everting the bowel prior to suturing the edge
to the skin (ie, Brooke technique) produces a spigot
conformation that holds a stoma appliance and prevents
serositis (see the image below), inset in part A). Eversion is
not always possible in neonates (in whom the blood supply
may be tenuous) and in situations in which the bowel is
markedly edematous. In these cases, the bowel is left to
protrude through the skin without eversion, and the stoma
automatically matures as the mucosa rapidly grows over the
exposed serosal surface.
Stoma location
Intestinal stomas can be exteriorized on the neck, chest, or
abdomen. The abdomen is by far the most common site for
intestinal stomas. Enterostomies can be brought through the
abdominal wall in the laparotomy incision or through a
separate site. Theoretical disadvantages of bringing a stoma
through a large laparotomy incision include the risk of wound
infection, dehiscence, and evisceration. Nevertheless stomas
are often incorporated into the incision, especially when the
only goal of surgery is to create a stoma. Whenever clinically
feasible, a primary stoma site, as well as alternative sites,
should be selected and marked before surgery. The ideal
location for an abdominal stoma in older children and
adolescents is similar to that in adults. The stoma is distant
from the incision, through the midportion of the rectus
muscle away from skin folds (eg, groin, flank), bony
prominences (eg, rib cage, iliac spine), and umbilicus (see the
images below).
Stoma location in infants and neonates follows these same
principles whenever possible; however, the small size of the
abdominal wall in infants and the short mesentery of the
bowel chosen for the stoma often limit the options. For
temporary stomas in infants, the bowel can be brought out
directly through or adjacent to the umbilicus (see the images
below).2 This site is easier for appliance placement and
results in a cosmetically superior scar when the stoma is
ultimately closed.
Potential sites for
neonate and infant
stomas.
Potential sites for stomas in an
older child or adolescent. Ideally,
a stoma is brought through the
rectus muscle in a position that
allows placement of a stoma
appliance.
Stoma brought directly
through the umbilicus.
Stoma matured through a
separate
inferior
umbilical
incision.
Workup
Laboratory Studies
Laboratory investigations depend on the indication for a
stoma.
Imaging Studies
1. Imaging studies may be performed as part of the
evaluation of the specific disease process and may
include the following:
 Plain radiography
 Contrast enema examination (particularly before closure
of stomas)
 CT scanning
 Ultrasonography
2. Prior to reversal of most ostomies in infants, consider
performing a distal contrast study to evaluate the
unused portion of the bowel. This is particularly
important in babies treated for neonatal necrotizing
enterocolitis with a diverting ostomy. Such patients may
have an unrecognized distal intestinal stricture. Repair of
the stricture is essential prior to, or during, the
procedure for reversal of the ostomy.
Diagnostic Procedures
Intestinal biopsy: In selected cases in which a colostomy or
ileostomy was performed for intestinal obstruction of unclear
etiology, a mucosal biopsy might be helpful to rule out the
possibility of Hirschsprung disease.
Treatment
Medical Therapy
Stomas are created for the treatment of surgical diseases
when no medical alternatives are available.
Surgical Therapy
The operation performed depends on the specific disease
being treated. Injuries to the rectum and sphincter are
difficult to repair in the initial setting. Minor injuries may be
primarily repaired. For more extensive injuries, exploratory
laparotomy should be performed to rule out intra-abdominal
injuries, and a diverting colostomy should be created.
Debridement of the perineum should be avoided in the initial
setting. The anal sphincter can be reconstructed later.
Preoperative Details
Stomas are created in both elective and emergency settings.
A physician, enterostomal therapist, or nurse specialist
should counsel children undergoing elective colostomy as
well as their families. This preparation reduces their anxiety
and makes postoperative management easier. When safe to
do so, the bowel is prepared mechanically and with
antibiotics; however, this preparation should be avoided
when an obstruction is present.
The potential stoma sites should be marked preoperatively.
In older children, the site should be marked with the patient
in both the sitting and supine positions to ensure that the
stoma appliance fits securely. The stoma site should be
selected to avoid fat folds, scars, and bony prominences. A
useful selection technique is drawing a vertical line through
the umbilicus to the pubis and a transverse line through the
inferior margin of the umbilicus. A disk the size of a stoma
faceplate can then be used to determine the location. When
an adequate site for all positions is found, the site should be
marked with ink. After the induction of general anesthesia in
the operating room, a fine needle can be used to scratch the
site prior to preparation of the abdominal skin.
Intraoperative Details
Construction of a stoma requires the bowel to be mobile
enough to be brought through the abdominal wall. Tension
on the mesentery should be avoided. Ideally, stomas are
brought out through separate skin incisions, but the clinical
situation ultimately dictates the site used. In older children
and adolescents, stomas should be brought through the
rectus abdominus muscle to prevent parastomal hernias. A
disk of skin is removed, and the fascia is incised
longitudinally. The stoma is matured with absorbable suture
after the abdominal incision is closed. In neonates and
infants, the stomas may be covered with Vaseline gauze until
bowel function returns. In older children, a 1-piece stoma
appliance that can be cut to just fit around the stoma should
be applied in the operating room.
Postoperative Details
Return of bowel function varies and depends on the clinical
setting. Ileostomies and colostomies usually begin to function
in 4-5 days. In the first few days, clear or serosanguinous fluid
may appear. This finding should not be mistaken for an
indication of bowel activity. An enterostomal therapist or
nurse specialist should be involved early in the care of the
newly formed stoma and in teaching the patient and family
long-term care of the stoma.
Follow-up
Small bowel stomas (ie, jejunostomy, ileostomy) and
proximal colostomies have liquid output. Volumes may be
large, and the fluid may irritate the skin. Use of an
appropriately fitting stoma bag is essential. Various stoma
appliances and products are available. Stoma appliances
should be able to remain in place for several days. Improperly
fitted appliances leak and lead to more complications.
Local irritation, skin excoriation, and yeast infections can be
treated with appropriate topical medication and skin care.
Mild stoma bleeding is not uncommon and usually stops
spontaneously. Children with high ostomy output require
close follow-up for dehydration and electrolyte imbalances.
Complications
Stoma-related complications
Many potential stoma-related complications are recognized.
Skin irritation and infection are the most common
complications with pediatric stomas. Excoriation from stoma
effluent, candidal infection, and dermatitis are frequent;
improper location or construction of the stoma and poor
stoma care are often responsible. Local wound care and
patient or caretaker education often corrects the problem.
Occasionally, surgical revision is needed. Wound infection,
wound separation, dehiscence, and postoperativesepsis may
also occur after formation of a stoma, particularly if the
stoma has been brought out through the wound.
Stoma prolapse also is common in children. Prolapse can
occur in end or loop stomas. Both proximal and distal bowel
segments can protrude many centimeters (see the image
below), although this complication may be more common in
the distal limb. A variety of surgical techniques have been
used, with mixed success, to reduce the incidence of
prolapse. Once prolapse occurs, it often becomes a chronic
problem that can be difficult to correct. In most cases,
prolapse is an unsightly nuisance but is well tolerated by the
child. Surgical revision is indicated for the rare instances of
ischemia, obstruction, ulceration, or chronic bleeding. Stoma
reversal is the optimal treatment.
Stoma retraction results in a stoma that is flush with the skin,
and difficulty in controlling the effluent may result in
significant skin breakdown. Retraction of a loop colostomy
results in a blowhole configuration that allows proximal
contents to spill into the distal segment. Revision may be
required if distal diversion is necessary. A retracted end
stoma often re-protrudes spontaneously. In most cases in
which the stoma is temporary, only short-term measures are
needed until the stoma is reversed. Permanent stomas that
have retracted may require surgical revision.
Appearance of
violaceous rash
commonly due
to Candida
albicans. String
coming out of the
distal stoma was
passed through a
distal stricture and
out of the anus.
Skin irritation, stoma
retraction,
and
wound
infection
after placement of a
stoma through a
laparotomy incision.
Wound infection and
postoperative sepsis
may also occur after
formation of a
stoma. Note the
redness of the skin at
the laparotomy
incision site and
evidence of soft
tissue abdominal
wall infection.
Prolapse of loop
colostomy. Both
proximal and distal
limbs have
prolapsed. This may
or may not cause
intestinal
obstruction.
Intestinal obstruction is also common. Stoma strictures can
occur at the skin level, fascial level, or both. Partial
obstruction can result in hyperperistalsis and hypersecretion;
massive fluid losses through the stoma may result in
dehydration. If a stoma stricture is suspected, the size of the
opening can be determined by carefully passing metal sounds
through the stoma. Attempts at dilating the stoma are
usually unsuccessful and may cause intestinal perforation.
Passage of a soft catheter proximal to the stricture can
provide temporary decompression. Most significant stoma
strictures require surgical revision; a local procedure with
minimal morbidity is often possible. Parastomal hernias
usually require surgical intervention.
Other causes of obstruction include luminal plugging caused
by ingested food, adhesive intestinal obstruction, internal
hernia, and volvulus. Obstruction is usually obvious, and the
diagnosis is based on the patient's history and findings at
physical examination and on plain radiography. In all patients
with a bowel obstruction, a nasogastric tube should be
placed for decompression and the patient should receive
intravenous hydration. A study with water-soluble contrast
material administered through the stoma provides diagnostic
information and, in most cases of luminal obstruction, is
therapeutic. Most adhesive obstructions improve with
nasogastric decompression and bowel rest. Prompt surgical
exploration is required in patients with suspected ischemic or
gangrenous bowel, clinical deterioration, or obstruction that
does not rapidly resolve with nonsurgical therapy.
Psychological issues can be significant for the child and the
family.5 These effects can be particularly important in
adolescents, who are dealing with body image and sexuality.
A team approach to providing preoperative counseling,
postoperative care, and rehabilitation is crucial to the wellbeing of the patient. An enterostomal therapist or nurse
specialist is essential. The age of the patient and an
understanding of physical and psychological changes that
children with stomas experience must be carefully
considered.
In summary, potential stoma-related problems include the
following:
1. Skin irritation - Chemical, mechanical, allergic
2. Intestinal obstruction - Adhesion, volvulus, internal
hernia
3. Wound-related complications - Infection, separation,
dehiscence
4. Infections
5. Prolapse
6. Retraction
7. Stricture
8. Fistula
9. Ulceration
10. Leakage
11. Bleeding
12. Parastomal hernia
13. Fluid and electrolyte imbalances
14. Psychological trauma
Fluid and electrolyte problems
Physiologic abnormalities related to loss of fluid and
electrolytes are common in young patients with stomas,
particularly when the stoma is in the proximal
gastrointestinal tract. Fluid and electrolyte losses from any
stoma can be significant, and replacement is usually required.
The electrolyte composition of enteral fluids is listed in the
following Table.
Electrolyte Composition of Enteral Fluids
Fluid
Na+
ClK+
HCO3 - H+
mEq/L mEq/L mEq/L mEq/L mEq/L
Saliva
30-60
15-40
20
15-50
N/A
Gastric
60-100 90-140 10-20 N/A
30-100
Duodenal 140
80
5
50
N/A
Bile
140
100
5-10
40-50
N/A
Pancreatic 140
75
5-15
90
N/A
Jejunal
100
100
5-10
10-20
N/A
Ileal
130
110
10
30
N/A
Colonic
60
40
30
20
N/A
Diarrhea
130
30
90
N/A
N/A
Duodenal stomas are rare, but duodenal fistulas may occur
after trauma or surgery. Duodenal fistulas typically have high
output and, therefore, are difficult to control. Proximal
jejunal stomas also tend to have high-volume output, with
fluid and electrolyte losses similar to those of duodenal
fistulas, except for a slightly lower sodium loss from the
jejunum. Pancreatic and biliary fluids also empty into the
duodenum, and secretion of these fluids may substantially
increase if feeding into the stomach is initiated.
Often, the proximal bowel can adapt to the fluid and
electrolyte losses of a distal small bowel stoma. After a
period of adaptation, the absorptive capacity of the small
bowel proximal to the ileostomy increases, and the bowel
can reduce ileostomy electrolyte losses by as much as two
thirds of its initial output. Adaptation of water absorption is a
much slower process. Ileostomy output should average 10-15
mL/kg/d. A doubling of usual stoma output should be
considered abnormal. Normal ileostomy output results in the
loss of 2-3 times the normal amount of salt and water, and
children with these stomas are susceptible to dehydration. In
infants, sodium and bicarbonate losses may exceed renal
conservation mechanisms. Infants are prone to dehydration,
and they may not gain appropriate amounts of weight unless
salt and bicarbonate supplementation is provided.
Patients with long-standing ileostomies often have
hypomagnesemia and decreased absorption of vitamin B-12
and folic acid. Patients with ileostomies also have a higher
incidence of renal calculi and gallstones than that of the
general population. Also, they may have iron deficiency and
fat malabsorption.
Intestinal contents become progressively more solid as they
pass through the colon to the rectum. The contents of the
ileum and cecum are liquid and erosive to the skin. The
contents of transverse colon stomas are typically semiliquid
and less erosive, whereas those of the descending colon tend
to be solid and nonreactive to the skin. These generalizations
are true when the proximal bowel has sufficient length to
allow absorption of nutrients and fluid. In children with short
bowel syndrome, fluid and electrolyte losses can be massive,
even with a distal colostomy.
Outcome and Prognosis
The outcome of patients with intestinal stomas depends on
the underlying condition. Fortunately, most stomas in infants
and children are reversible. Reestablishing bowel continuity
depends on factors such as the underlying disease, the
general medical condition of the child, and the presence of
stoma-related complications. Understanding the anatomy
prior to stoma closure is crucial. In most instances, a
preoperative distal contrast-enhanced study should be
performed.
In general, the prognosis for patients with intestinal stomas is
good. The exception is in patients with stomas and short gut
syndrome. In such cases, reversal of the stoma should be
attempted as soon as possible in order to maximize the
absorptive capacity of the intestines. However, in many cases
of short gut syndrome, ostomy reversal is not possible
because of other associated comorbid conditions. The most
common cause of short gut syndrome in North America is
necrotizing enterocolitis.
Future and Controversies
In selected cases, performing ostomies using minimally
invasive surgical technique (laparoscopic surgery) is possible.