Pouch problems: troubleshooting your appliance
Sunday, September 30, 2018
How to recognise common issues with your ostomy pouch and find the smartest way to fix them
A stoma can save your life, and it can be liberating. Unfortunately, it can also cause you problems. A healthy stoma with a secure and comfortable appliance takes a little upkeep, and every ostomate will have to deal with some common issues. A troubled stoma can cause serious physical and emotional discomfort, but luckily almost all of these issues can be fixed with the right approach. This article will address some specific issues relating to the ostomy appliance (or pouch). Issues affecting the stoma itself and the surrounding (peristomal) skin will be covered in future issues of Stoma Tips.
The best way to prevent pouch problems is to make sure you are using the right appliance for your own needs. For a guide, take a look at the article ‘Choosing the right appliance’ from the first issue of Stoma Tips.
Priority number one in stoma care is to make sure the pouch forms a strong seal with the skin. Should the seal fail, the output will leak out, causing sore skin and an unpleasant odour. Although leaks are common, they are preventable. Whenever you experience a leak, you should do what you can to establish the cause and fix it.
This is something your stoma care nurse will be able to help you with. Changing a pouch is a skill that takes a little learning, and an experienced nurse can help improve your technique. This could be showing you where to place the pouch, how to put it on and take it off safely and correctly, or how to measure and cut the template.
Everyone’s body is different, and you and your stoma care nurse should get to know the particular needs of your stoma and the surrounding skin. The shape and condition of the skin around your stoma affects what is needed to form an effective seal. If you are one of the many people whose skin is not entirely flat, with dips and folds, then these can be filled in to create a flat surface using adhesive paste and stoma seals. Should you have a parastomal hernia—a section of bowel protruding through abdominal muscles under the skin and forming a bulge or mound—this may require a larger flange to secure the pouch over the hernia. If the stoma is flush (flat) against the skin or retracted beneath it, then a nurse can advise on solutions, including convex pouches. If the skin is too sore or damp for a seal to form, then the nurse can assess the condition and help find a solution. Sometimes, the adhesive material of a particular pouch doesn’t work with someone’s skin, and they can try one with a softer or more adhesive flange.
Reduce ballooning by unblocking the filter, adjusting your diet or changing appliance
Ostomy appliances are designed to be fully odour-proof, including the filter, which should only let out odourless air. However, if you detect an odour while wearing your pouch, you should immediately check for a leak, as this is almost certainly the cause.
If there is an especially strong smell when emptying or changing the pouch, it is likely that your diet is increasing the odour. In this case, it may help to cut down on foods such as fish, beans and eggs, as well as certain vegetables, such as cabbages turnips, onions and parsnips. To make changeing your appliance easier, before you begin, you can spray room freshener or other pleasant-smelling substance into the air and/or the toilet. Sucking on a mint when changing pouches can also help you deal with any odour.
Ballooning, as the name suggests, occurs when the pouch fills up with flatus, the gasses naturally produced by your stoma. Most modern pouches are equipped with a filter to let excess flatus out. If this is not doing the trick, first check to see if it has become blocked or covered over. If the filter is clear, it may simply be struggling to keep up with the amount of flatus being produced.
In this case, you can try to reduce the amount of flatus you are producing. This can be done by altering your dietary intake slightly. It helps to have regular meals, eat slowly and not skip on mealtimes. You can also cut down on foods known to increase flatus, such as cabbage, beans and sprouts, as well as beer. Swallowing lots of air as you drink also creates extra flatus, so you might want to avoid carbonated (fizzy) drinks and not drink through straws.
These tips should cut down on flatulence and deflate any ballooning. However, if your pouch is still blowing up, you may wish to shop around for an appliance with a more suitable filter. Some pouch filters have caps that can be removed to allow the air out.
Tackle pancaking with fluids, fibre, filter covers, pouch lubricant or a convex pouch
Pancaking, not as tasty as it sounds, is a common issue for colostomates. The output of a colostomy tends to have a solid, formed consistency. This means it sometimes doesn’t drop into the pouch properly and instead becomes stuck to the stoma itself, creating a pancake. This can then cause the pouch to lift off the skin, which makes leaks more likely. Pancaking usually happens when the output has a particularly thick consistency. It can also occur when the pouch filter works too well at removing the air and inadvertently creates a vacuum.
Should you find pancaking on your stoma, the first thing to do is to thin the consistency of your output to help it drop into the pouch better. This can be done by drinking plenty of fluids and increasing the amount of fibre in your diet, perhaps by eating more wholegrains or certain fruits or vegetables.
To reduce the vacuum effect, you can cover the filter to keep the air in your pouch. A new box of pouches often comes with stickers for this purpose. However, a covered filter can keep too much air inside and cause ballooning, in which case the sticker will need removing as necessary.
If pancaking continues, there are some extra steps to take before you change your appliance. If you lubricate the inside of the pouch with baby oil or an equivalent, it can help the output drop into the pouch. Meanwhile, putting a piece of tissue inside can help reduce the vacuum effect. Trying a different type of pouch may help, and you can ask your nurse whether it might help to use a convex appliance.
Ileostomates have a shorter bowel with which to absorb water, and so their output is often porridge-like or loose in consistency. This makes the pouch fill faster and more likely to leak, as well as causing dehydration. Therefore, excessively high volumes should be monitored.
Output can be thickened with a change in diet. It helps to eat regularly and to eat more of foods that thicken output, including marshmallows, jelly, pasta, noodles, potatoes and rice. If dietary changes are not enough, you can ask your nurse whether it you should try output-thickening medications, such as loperamide. If watery output continues to cause leaks, you can ask about adding thickening sachets to your prescription; these sit in the pouch and absorb liquid output.
Thicken watery output with different foods, loperamide or pouch sachets
It is possible that your skin will react poorly to one of the various materials used in stoma appliances. As an allergic reaction can be difficult to distinguish from a skin problem caused by a leak, you will have to ask your nurse to help work out what caused it. Sore skin, where there are no other signs of a leak detected, may be caused by an allergic reaction to a stoma care product. These reactions are usually topical, only affecting the skin that is directly touched by the material, so the sore area may have the same size and shape as the pouch’s flange.
Ostomy appliances are typically made of either silicone or hydrocolloid, which is considered to be hypoallergenic, and this may also be infused with other substances, such as ceramide, aloe vera, vitamin E and manuka honey. Skin can also react to ingredients in other products, such as adhesive removers, skin barriers and elastic tapes. This is one reason why, in stoma care, less is often more, and fewer products can reduce the risk of problems.
Establishing which, if any, of these materials are causing a reaction requires trial and error, using a variety of pouches made of different materials, as well as potentially swapping out other stoma care products. Your nurse can help you order a selection. Once an offending material is identified, you can change your prescription to solve the problem.
Although stomas take a little caring for, they shouldn’t cause distress. Every issue has a solution, and there are a great many resources that are available to support you. There is also a wealth of information and support available from support groups, online communities and nurses, so there is no need to suffer in silence.
Ginny Hill is a colorectal clinical nurse specialist at Walsall Healthcare NHS Trust
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