Total body water and total body potassium in ileostomy patients before and after conversion to the continent ileostomy

The case of spontaneous stoma closure in patient with loop ileostomy

Introduction

An ileostomy is a mean to empty the contents of the bowel via ileum rather than usual anal route to prevent distal anastomotic leak. It is considered a controlled entero-cutaneous (EC) fistula which prevents contamination of peritoneal cavity, protecting the peri-stomal skin from effluent and excoriation. Spontaneous closure of ileostomy is a very rare phenomenon. Thus, we hereby report a case of spontaneous closure of ileostomy.

Case presentation

An 18-years male presented with complaints of pain abdomen, vomiting for 6 days. Chest X-ray showed free air under the right dome of diaphragm suggestive of pneumo-peritoneum. So explorative laparotomy with primary repair of ileal perforation with diversion loop ileostomy (2 ft proximal to ileocecal junction) was performed. Over the months stoma retracted and eventually spontaneous closure of stoma took place after 4 months of surgery.

Discussion

Retraction of stoma depends on multiple factors. Firstly, on patient's general condition, if he/she is malnourished/obese/immunocompromised then retraction occurs due to poor healing of wound. Secondly, it results from inadequate mobilization of bowel. Separation of stoma with muco-cutaneous fascial planes leads to gradual retraction of stoma which is primary mechanism of spontaneous closure of stoma.

Conclusion

To summarize, gradual retraction of stoma (complication of an ileostomy) and healing of EC fistula has to be correlated to know the complex mechanism of spontaneous closure of an ileostomy.

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Retracting ileostomy can be considered analogous to healing of enterocutaneous fistula.

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Stoma retraction is a multi-factorial phenomenon.

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More research is needed to arrive on logical and detailed conclusion on the subject.

Spontaneous closure of an ileostomy: A rare occurrence

INTRODUCTION

Ileostomy is an iatrogenic entero-cutaneous (EC) fistula designed for controlled evacuation of bowel contents. Once ileostomy has served its purpose, it is reverted by surgical procedure. We are reporting an interesting case of spontaneous closure of an ileostomy, obviating the need of surgical intervention.

PRESENTATION OF CASE

A 26 year old lady presented with perforation peritonitis. Upon exploration, a tubercular perforation of terminal ileum was found. Loop ileostomy was formed and patient was discharged on anti-tubercular treatment (ATT) after an uneventful recovery. During follow up visits, stoma was found to be retracting gradually. Retraction was not associated with any signs of peritonitis. Patient was able to pass stools per rectally. Stoma regressed completely within 8 months followed by epithelialisation of stoma site. Patient was leading an essentially normal life until her last follow up visit.

DISCUSSION

Considering the various factors affecting spontaneous healing of EC fistulas, all the intestinal stomas do have favourable characteristics essential for spontaneous closure. However, this is seldom seen in day to day surgical practice. The factors pertaining to this particular case that led to spontaneous closure of stoma remain poorly understood.

CONCLUSION

Further research is warranted to understand the mechanism behind spontaneous regression of a stoma. Relationship between this event and intestinal tuberculosis or ATT needs to be analysed.

Total exchangeable sodium related to body composition in patients with conventional or reservoir ileostomy

Decreased exchangeable body sodium might be a consequence of proctocolectomy and construction of an ileal reservoir. To investigate this, 35 patients with ulcerative colitis and conventional ileostomy were studied before and after conversion to continent ileostomy and compared with 25 unoperated subjects as reference. The sodium urinary excretion varied between 7 and 229 and 1 and 217 mmol/24 h in patients with conventional and reservoir ileostomy, respectively. The total exchangeable sodium was measured and related to body composition estimated from body weight, total body water, and total body potassium. No effect on exchangeable sodium was observed after conversion: 3100 mmol and 2990 mmol, respectively. Patients with ileostomy, regardless of type, did not differ from reference subjects in their exchangeable sodium when related to total body water. A larger variation of total exchangeable sodium related to total body water suggests unstable sodium homeostasis in patients with ileal reservoir compared with reference subjects.

Sodium and potassium excretion before and after conversion from conventional to reservoir ileostomy

Sodium and potassium in the ileostomy output and urine were determined in 28 patients with ulcerative colitis on a free diet and in eight patients on a defined constant diet, before and after conversion from a conventional ileostomy (CI) to a continent reservoir ileostomy (RI). Feces and urine were collected both in the hospital and at home. Patients with CI on free diet had a median intestinal loss of 62 mmol sodium and those with RI 74 mmol/24 h collected in the hospital (p < 0.05). The figures for at home was 79 and 81 mmol/24 respectively, and were larger than in the hospital (p < 0.01). Sodium loss in the urine (U-Na) and the intake of sodium did not change significantly after conversion. Patients with a low U-Na before conversion also had a low U-Na after, in a few almost nil, implying a need for increased intake of sodium. Patients with a CI and low urinary output of sodium should be carefully studied with respect to their sodium balance before accepting them for conversion to RI. The ileostomy output of potassium increased after conversion (4.3 vs. 6.8 mmol/24 h; p < 0.01) in the hospital (5.3 vs 7.1 mmol/24 h; p < 0.01) at home. Patients on a defined constant diet before and after conversion did not show any significant differences in absorption of sodium, potassium, magnesium or calcium after conversion, but did show a reduced dry weight of the ileostomy output, indicating an increased degradation of intestinal contents in RI patients.(ABSTRACT TRUNCATED AT 250 WORDS)

Water and electrolyte balance after ileoanal anastomosis

Water and electrolyte balance was studied in 30 patients with ileoanal anastomosis and J pouch, 10 patients with conventional ileostomy, and nine nonoperated patients with quiescent ulcerative colitis. Serum electrolyte concentrations, daily urinary volume, and daily losses of sodium, potassium, and chloride were measured in all patients. Daily fecal weight and daily losses of sodium and potassium were analyzed in patients with ileoanal anastomosis or conventional ileostomy. Serum chloride in patients with ileoanal anastomosis was significantly lower (P less than 0.05) than in those with conventional ileostomy or in nonoperated patients. Daily urinary loss of sodium in nonoperated patients was significantly higher than in patients with ileoanal anastomosis (P less than 0.01) or conventional ileostomy (P less than 0.05). Daily urinary loss of chloride in patients with ileoanal anastomosis was significantly lower (P less than 0.05) than in nonoperated patients. Daily fecal loss of potassium in patients with ileoanal anastomosis was significantly higher (P less than 0.05) than in those with conventional ileostomy. Daily urinary volume and fecal weight did not differ significantly in patients with ileoanal anastomosis or conventional ileostomy. The present study indicates that changes in water and sodium balance after ileoanal anastomosis are similar to those after conventional ileostomy but chloride balance is more altered after ileoanal anastomosis.

Long-term follow-up of patients with continent ileostomies

Thirty-six patients were evaluated after having continent ileostomies for 16 to 20 years. Follow-up included clinical examination, response to a questionnaire, blood tests, and radiologic studies of the gallbladder. In addition, reservoir biopsies from 15 patients were examined. The patients were in excellent general health, all but one having gained weight postoperatively. There was no increased risk for gallstone formation or for urinary tract stone development. Although 11 of the 36 patients had reservoirs that were not provided with a valve, 92 percent of all patients were continent. Working capacity was normal in most patients and no harmful effects of the reservoir were revealed by morphologic or biochemical studies. In conclusion, no deleterious long-term effects were found as a result of the continent ileostomy.