Stoma for short case in practical exam
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Stoma - Short Case for Practical Exam
Introduction (What to say at the start)
"On examination, there is a stoma in the [right/left iliac fossa / right upper quadrant]. It is a [single/double]-lumen stoma [with/without] a spout. The bag contains [liquid/semi-formed/solid faeces / urine]. The surrounding skin appears [healthy / erythematous / excoriated]."
Step 1 - Examination Approach (IPPE)
Inspection first, then assess specific features:
| Feature | What to look for |
|---|---|
| Site | RIF vs LIF vs other |
| Number of lumens | 1 (end) vs 2 (loop) |
| Spout | Present = ileostomy/urostomy; Absent = colostomy |
| Effluent | Liquid = ileostomy; Semi-formed/solid = colostomy; Urine = urostomy |
| Surrounding skin | Excoriation, erythema, fistula |
| Scars | Indicate underlying surgery / disease |
Step 2 - How to Identify the Type of Stoma
This is the most common question asked in short cases. Use the 3-point method:
A. Site
| Stoma | Typical Location |
|---|---|
| End ileostomy / loop ileostomy | Right iliac fossa (RIF) |
| End colostomy (sigmoid) | Left iliac fossa (LIF) |
| Loop colostomy (transverse) | Right upper quadrant / upper abdomen |
| Urostomy (ileal conduit) | Right iliac fossa (may overlap with ileostomy) |
B. Spout
- Spout present (stoma protrudes ~2-3 cm above skin) = Ileostomy or Urostomy
- The spout prevents liquid / corrosive contents from irritating the peristomal skin
- Flush / no spout = Colostomy
- Colonic content is formed, less irritating, so no spout needed
C. Effluent / Output
| Effluent | Type |
|---|---|
| Liquid / watery green-brown | Ileostomy |
| Semi-formed to solid brown | Colostomy |
| Clear / pale yellow (urine) | Urostomy |
D. Number of Lumens
| Lumens | Type |
|---|---|
| 1 lumen | End stoma (ileostomy or colostomy) |
| 2 lumens | Loop stoma (proximal = functioning, distal = mucous fistula) |
Step 3 - Types of Stoma in Detail
1. End Ileostomy
- Site: RIF
- Spout: YES (~2-3 cm)
- Lumen: 1
- Output: Liquid, high volume (500-1500 mL/day)
- Permanent indications: Proctocolectomy for UC, FAP, Crohn's
2. Loop Ileostomy
- Site: RIF
- Spout: YES
- Lumen: 2
- Use: Temporary diversion to protect distal anastomosis (e.g. low anterior resection, ileal pouch)
- Easily reversed later
3. End Colostomy (Hartmann's / Sigmoid)
- Site: LIF
- Spout: NO (flush)
- Lumen: 1
- Output: Formed stool
- Permanent indications: Abdominoperineal resection (APR) for low rectal cancer
- Hartmann's procedure: emergency for perforated diverticulitis / obstructing sigmoid cancer
4. Loop Colostomy
- Site: Usually right upper quadrant (transverse colon) or LIF (sigmoid)
- Spout: NO
- Lumen: 2
- Use: Emergency decompression, temporary diversion
- Note: Transverse loop colostomy prone to prolapse, avoid if possible (Sabiston)
5. Urostomy (Ileal Conduit)
- Site: RIF
- Spout: YES
- Lumen: 1
- Output: Urine
- Indication: After cystectomy (bladder cancer, neurogenic bladder)
Step 4 - Complications to Know (Asked in Viva)
From Bailey & Love (28th Ed) and Fischer's Mastery of Surgery:
| Complication | Features |
|---|---|
| Skin irritation / excoriation | From leaking effluent, most common |
| Stenosis | Narrowed stoma opening, difficulty passing stool/urine |
| Prolapse | Stoma protrudes excessively; look for it on inspection |
| Parastomal hernia | Bulge around stoma; ask patient to cough to demonstrate; very common |
| Retraction | Stoma sinks below skin level; poor seal, leakage |
| Ischaemia / Infarction | Dusky/black stoma; emergency - ligation of blood supply, operative trauma, venous obstruction |
| Bleeding | From mucosal trauma |
| Fistulation | Track from bowel to skin |
Parastomal hernia is the most common long-term complication of colostomy.
Step 5 - Indications (Common exam questions)
Why does this patient have a stoma?
Common underlying conditions:
- Colorectal cancer - APR for low rectal ca (permanent colostomy); Hartmann's for obstructed/perforated sigmoid ca
- Ulcerative colitis - Proctocolectomy + end ileostomy
- Crohn's disease - Stricture, fistula, perianal disease
- Diverticular disease - Perforated diverticulitis (Hartmann's)
- Intestinal obstruction - Decompressing colostomy
- Trauma - Bowel injury
- Bladder cancer - Urostomy (ileal conduit)
Step 6 - Viva Questions to Prepare
Q: How do you differentiate ileostomy from colostomy?
Use the 3 features: Site + Spout + Effluent
- Ileostomy: RIF + Spout + Liquid output
- Colostomy: LIF + No spout + Solid output
Q: What is a Hartmann's procedure?
Resection of the sigmoid colon / upper rectum with closure of the rectal stump (left as Hartmann's pouch) and formation of an end sigmoid colostomy. Done in emergency settings. Can be reversed later if patient fit.
Q: What is APR?
Abdominoperineal resection - removal of rectum, anus, and sphincter complex for very low rectal cancer. Results in permanent end colostomy.
Q: What is an ideal site for a stoma?
- Should be preoperatively marked by stoma nurse / surgeon
- Within the rectus abdominis muscle (reduces parastomal hernia risk)
- Away from bony prominences, skin folds, scars, umbilicus, and belt line
- Infraumbilical fat mound is often the ideal site (Sabiston)
Q: What is a loop vs end stoma?
- End: Single bowel end brought to surface; permanent or temporary
- Loop: Loop of bowel brought out with a rod/bridge; both lumens visible - proximal (functioning) and distal (mucous fistula); always temporary
Q: How do you close a loop ileostomy?
Reversal (takedown): Close the two lumens with a side-to-side anastomosis (usually 8-12 weeks after original surgery).
Step 7 - Example Short Case Presentation
"I examined this [age/sex] patient who has a stoma in the right iliac fossa. It is a single-lumen stoma with a spout, and the bag contains liquid brown faeces. There is no evidence of parastomal hernia, prolapse, ischaemia, or peristomal skin excoriation. The abdominal scar suggests a previous midline laparotomy. These findings are consistent with a functioning end ileostomy, most likely formed following a proctocolectomy for inflammatory bowel disease or colorectal malignancy."
Quick Comparison Table
| Feature | Ileostomy | Colostomy | Urostomy |
|---|---|---|---|
| Site | RIF | LIF (end) / RUQ (loop) | RIF |
| Spout | YES | NO | YES |
| Lumens | 1 (end) or 2 (loop) | 1 (end) or 2 (loop) | 1 |
| Output | Liquid faeces | Solid/semi-formed | Urine |
| Mucosa | Pink, moist, granular | Pink, smooth | Pink |
| Common indication | UC, Crohn's, cancer | Rectal cancer, diverticular | Bladder cancer |
| Reversible? | Often yes | Sometimes | No |
Sources: Bailey & Love's Short Practice of Surgery, 28th Ed.; Sabiston Textbook of Surgery; Fischer's Mastery of Surgery, 8th Ed.; Geeky Medics OSCE Guide
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