Before reduction is attempted, the edema of the prolapse may be reduced by applying cool compresses or osmotic agents such as honey or sugar for approximately 30 minutes. The prolapse is then lubricated with a water‐soluble lubricant, and with gloved hands, circumferential pressure is applied on the prolapsed mucosa. Placing a finger in the center of the prolapse may help guide the reversal process. After the prolapse is reduced, an abdominal binder should be placed, and the patient should be instructed to avoid lifting or other activities that increase intra‐abdominal pressure and should follow up with their ostomy team as an outpatient. Complicated prolapses, prolapses causing ischemic changes or severe mucosal irritation and bleeding, and those that are unable to be reduced by the ED physician usually require surgery.
Stomal stenosis is a less common complication of ostomies with an incidence of 2–15% and more often seen in patients with Crohn's disease. Symptoms of stomal stenosis include noisy stoma when flatus is passed, reduced output, diarrhea, or cramping abdominal pain followed by explosive output. Severe stenosis may present with obstruction. The ED physician may assess for mild stenosis by digital exam or attempting to pass a catheter.
Figure 2.2 Irritant dermatitis.
(Source: Photo courtesy of Judith Stellar)
Cutaneous Complications
Dermatitis is common among patients with GI diversions and usually caused by the chronic effect of the proteolytic enzymes and high alkaline content of the stool and other drainage on the peristomal skin. The degree of irritation can range from mild dermatitis to severely denuded skin along the inferior aspect of the stoma (Figure 2.2). Fungal infections due to Candida albicans frequently accompany the dermatitis since the warm moist environment makes an ideal location for fungal infections. In these cases, the skin is often raised and erythematous with well‐circumscribed papules or satellite lesions. Application of clotrimazole or miconazole nitrate 2% powder is often sufficient for treating candidal infections. Mixing an antifungal powder with a small amount of water and then painting it onto the skin can enhance the adherence of the pouch. Contact dermatitis due to an allergic reaction from the stoma products or tape can also present with mild to severe skin breakdown; however, the hallmark of allergic dermatitis is the precise outline of the rash that matches the stoma product. Avoidance of the appliance and application of topical steroid cream and oral antihistamines are often helpful. Cellulitis can occur in the setting of severe excoriations and may require systemic antibiotics. The rash associated with cellulitis is usually more tender, warm, and indurated than in typical forms of irritant or allergic dermatitis.
Metabolic Derangements
Patients with ileostomies are at higher risk for metabolic derangements due to the larger volume of effluent that is produced daily. The normal adult output is 500–1300 ml/day, which may be increased in the setting of obstruction, infectious enteritis, bacterial overgrowth, and dietary indiscretion such as diets high in sugar, salt, and fat. High stoma output can lead to hyponatremia, hypokalemia, and hypomagnesaemia. If more than 60–100 cm of the terminal ileum is resected, malabsorption of fat and vitamin B12 can occur. The initial evaluation for high stoma output includes obtaining a set of electrolytes such as magnesium and phosphorous; a complete blood count to assess for anemia; a two‐view abdominal x‐ray; stool studies for Clostridium difficile, ova and parasite and bacterial culture; and obtaining a detailed diet history. Management of high stoma output includes identifying and treating the underlying cause. Patients with Crohn's disease may present with increased output as a sign of an acute flare, and gastroenterology consultation should be obtained for these patients. If the electrolytes are normal, and the patient is well hydrated and hemodynamically stable with a benign abdominal exam, the patient may be discharged home with instructions to increase their fiber intake and decrease their intake of sugar, salt, and fat. For patients with metabolic derangements, dehydration, or other concerns, intravenous fluids, electrolyte replacement, and bowel rest are the initial steps. Once the patient is stabilized, long‐term management of high stoma output may include antidiarrheal agents including loperamide, oral fluid restriction, dietary salt supplementation, H2 antagonists, and proton pump inhibitors. Patients with ileostomies are also predisposed to kidney stone formation due to their state of chronic mild dehydration and acidic urine.
Consultation
ED physicians can manage many of the complications from GI diversions such as small parastomal hernias, uncomplicated prolapses, and dermatitis. Cases of early postoperative complications and any concern of ischemia require immediate surgical consultation.
Further Reading
1 1 Bafford, A.C. and Irani, J.L. (2013). Management and complications of stomas. Surg. Clin. N. Am. 93: 145–166.
2 2 Fine, J.A., Cronan, K.M., and Posner, J.C. (2010). Approach to the care of the technology‐assisted child. In: Textbook of Pediatric Emergency Medicine, 6e (eds. G.R. Fleisher and S. Ludwig), 1510–1513. Philadelphia, PA: Lippincott, Williams and Wilkins.
3 3 Landman RG. Routine care of patients with an ileostomy or colostomy and management of ostomy complications (ed. Weiser M). UpToDate, 2016.
4 4 Martin, S.T. and Vogel, J.D. (2012). Intestinal stomas. Indications, management, and complications. Adv. Surg. 46: 19–49.
5 5 Shabbir, J. and Britton, D.C. (2010). Stoma complications: a literature overview. Colorectal Dis. 12: 958–964.
3 Management of the Bariatric Surgery Patient in the Emergency Department
Megan Lavoie1,2 and Joy Collins1,3
1 Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
2 Division of Emergency Medicine, Department of Pediatrics, Children’s Hospital of Philadelphia, Philadelphia, PA, USA
3 Division of General and Thoracic Surgery, Department of Surgery, Children’s Hospital of Philadelphia, Philadelphia, PA, USA
Introduction
Obesity, defined as BMI > 35 kg/m2, is becoming increasingly prevalent in the US and globally. According to the most recent Centers for Disease Control and Prevention (CDC) data, in the US, >35% of adults in the US are obese and close to 20% of children meet the definition of obesity or severe obesity (BMI > 40 kg/m2). Obesity brings with it significant physical and psychosocial comorbidities that carry a large health burden: type 2 diabetes mellitus, hypertension, obstructive sleep apnea, dyslipidemia, nonalcoholic steatohepatitis, and orthopedic complications, among others, have been seen in severely obese adolescents as well as in adults. Medical and psychological management alone is often not adequate to achieve significant, sustainable weight loss. Surgical weight loss techniques are increasingly being offered to severely obese patients experiencing comorbid conditions. According to the American Society of Metabolism and Bariatric Surgeries, in 2015, over 195 000 bariatric surgeries were performed in the US in adults or adolescents. Over 50% of patients had the gastric sleeve procedure, and approximately 25% underwent the Roux‐en‐y‐gastric bypass (RYGB). The adjustable gastric band is another surgical
