Stoma: ileostomy and colostomy
A piece of bowel brought to the skin to divert stool. The ED problems: a high-output stoma dehydrating the patient, obstruction (the stoma stops working), and a dusky or black stoma, which is ischaemia.
Also called: stoma, ileostomy, colostomy, end stoma, loop stoma, bowel stoma, high output stoma, stoma bag, ostomy
What it is
A bowel stoma is a loop or end of intestine brought out onto the abdominal wall so bowel content drains into a bag. An ileostomy (usually right side, a spout, liquid/porridge-like output) diverts small bowel; a colostomy (usually left side, flush to the skin, more formed stool) diverts colon. (A urine-draining stoma is an ileal conduit / urostomy - a different device, see that entry.)
The ED-relevant failures are about output and viability. A high-output stoma causes dangerous fluid and electrolyte loss: A high output stoma (HOS) is when the stoma output causes the patient to become water, sodium and magnesium depleted
, typically when the output is more than 2 L / 24 hours
(an adult figure; in children the thresholds are weight-based and set by the paediatric surgical team). The opposite - a stoma that stops - may mean obstruction. And a stoma that turns dusky or black is ischaemic. These are common in adults and, for congenital and inflammatory disease, in children.
How to recognise it
- A bag over an abdominal-wall stoma. An ileostomy typically spouts, sits on the right, and drains liquid output; a colostomy is flatter, often on the left, with more formed stool.
- A healthy stoma is pink/red and moist. A dark, dusky, purple or black stoma is a red flag for ischaemia; a stoma that has pulled below skin level (retraction) or prolapsed is also abnormal.
- A carer or patient who manages the stoma at home and usually knows their normal output volume and consistency - a change from that baseline is the clinically useful fact.
What it gets confused with
An ileal conduit (urostomy) is a stoma that drains urine, not stool, and is usually a spout on the right. If the bag contains urine, it is a urinary stoma - manage dehydration and obstruction differently (see the ileal-conduit entry). Check what the bag actually contains.
What goes wrong
High-output stoma with dehydration
Large-volume watery output, thirst, dizziness, reduced urine, acute kidney injury and low sodium/magnesium - especially a new or recently formed ileostomy.
Red flag
This is a fluid and electrolyte emergency, not just a 'leaky bag'. Rehydrate (often IV saline), check U&E and magnesium, and - counter-intuitively - Patients must restrict oral hypotonic fluid
(water worsens sodium loss), substituting an oral rehydration solution. Look for a treatable cause.
Obstruction (the stoma stops working)
A stoma that stops producing, with colicky pain, distension and vomiting. BIFA notes the clue: A history of sudden onset colicky abdominal pain, borborygmi, swelling/visible peristalsis and temporary stopping of the stoma are suggestive
.
Red flag
Treat as bowel obstruction: nil by mouth, fluids, decompression and surgical assessment. A food bolus, adhesions or a stricture at the stoma can all cause it; obstruction can paradoxically precede a surge of high output as it resolves.
Ischaemic stoma (dusky or black)
A stoma that has turned dark, dusky, purple or black, dry, or is sloughing.
Red flag
A black stoma is ischaemia and a surgical emergency - the concern is how far below the skin the dead bowel extends. Urgent surgical review; do not wait.
Retraction, prolapse, parastomal hernia or bleeding
A stoma that has sunk below the skin, prolapsed out as a long segment, bulged with a parastomal hernia, or is bleeding; often with leakage and skin breakdown.
Red flag
Most are managed with the stoma nurse and surgical team; the emergencies hidden among them are obstruction within a hernia (irreducible, painful, with obstruction) and ischaemia of a prolapsed segment (going dusky). Significant bleeding from the bowel itself, rather than the skin edge, needs assessment.
The first ten minutes
- Look at the stoma and the bag. Colour (pink = healthy, dusky/black = ischaemia), whether it is producing, and what and how much is in the bag.
- For a high output stoma, resuscitate and correct electrolytes - IV fluid if dehydrated, check U&E and magnesium, and restrict hypotonic oral fluid rather than encouraging 'drink plenty'.
- For a stoma that has stopped, with pain, distension or vomiting, treat as obstruction - nil by mouth, fluids, imaging and surgical review.
- For a dusky or black stoma, call the surgical team now - ischaemia is time-critical.
- Protect the peristomal skin and get the stoma care nurse involved for leakage, retraction, prolapse and appliance problems.
- Involve the surgical / stoma team for obstruction, ischaemia, incarcerated hernia or a stoma that will not settle.
Do not
Patients who need admission for rehydration should not just be rehydrated and discharged.
Who owns it
The colorectal / general surgical team and the stoma care nurse own the stoma; the nutrition / intestinal-failure team owns a chronic high-output stoma (and the paediatric team in children). Tell them the stoma type, the change from the patient's normal output, the stoma's colour and viability, and the U&E/magnesium.
Who to call
The team and the criteria are national. The phone number is local, and this tool does not know it. Find it once, now, and write it on the department's own card — that is the part no website can do for you.
- Say the device name first
- Open with laryngectomy, LVAD, shunt — the single word changes who comes and what they bring. Do not bury it in the history.
- Say what you have already established
- Whether the device is patent, whether it has been removed or disturbed, and what you have already tried. The specialist is deciding whether to walk or run.
- Ask who owns it out of hours
- Device ownership and the on-call route often differ from the implanting specialty, and it is frequently a regional centre rather than your own hospital.
- The patient's own team is a resource, not an afterthought
- Named nurse specialists, home-care companies and device helplines answer questions nobody else can, and the patient usually has the number.
When the device is not the problem
A patient with a device gets pneumonia, sepsis, pulmonary oedema and myocardial infarction at the same rate as everybody else. The device is the most visible thing about them and it attracts the whole assessment.
- The NTSP says it out loud
- The project's own manual warns that
patients with tracheostomies can become unwell with all the problems that other patients get too. It is easy to become fixated with the tracheostomy.
The same sentence applies to every device in this tool. - Clear the device, then leave it
- Establish that the device is doing its job — the stoma is patent, the line draws back, the pump is running — and then assess the patient as you would anyone else.
- The anchoring runs both ways
- The opposite error is treating a device complication as a medical illness: a blocked gastrostomy read as vomiting, a baclofen pump failure read as sepsis.
- NTSP manual — Red flags · read in full
What the patient will be carrying
Stoma patients and carers are usually expert in their own stoma, know its normal output and appliance, and often carry stoma-nurse contact details and spare supplies.
Scope of this page
This page covers the ED assessment of a bowel stoma: high-output dehydration, obstruction, ischaemia, and parastomal problems, and when to escalate. It does not teach stoma formation, routine appliance changes or the full outpatient high-output regimen (a surgical, stoma-nurse and intestinal-failure matter). The high-output definition and fluid/electrolyte figures here are from adult BIFA guidance; paediatric thresholds are weight-based and the ischaemia/obstruction recognition is established surgical practice. Stomas occur in adults and children; paediatric care is directed by the child's surgical team.