Authors
Alexander Boscia, MS3, Case Western Reserve University School of Medicine Debra Leizman, MD, FACP, University Hospital Cleveland Medical Center
Introduction
Stomal prolapse is a common late complication of stoma creation with variable incidence depending on bowel location, creation technique, disease process, or emergent vs elective creation1. Loop ileostomy is associated with the lowest incidence of prolapse at approximately 2%2. Risk factors include large abdominal-wall openings, inadequate bowel fixation to the abdominal wall during surgery, increased abdominal pressure, lack of fascial support, obesity, pregnancy, and poor muscle tone3. Although functionally benign and painless in most cases, rare complications of prolonged mucosal exposure include ulceration, bleeding and incarceration1. Each year, approximately 120,000 patients undergo ostomy surgery with up to 1 million patients with current temporary or permanent stomas4. It is therefore extremely common for a general internist to be faced with the care of an ostomate. Knowledge of the management of common stomal complications is essential in providing patients effective, high-value care and potentially avoiding of the need for surgery as demonstrated in this case.
Case Presentation
A 30 year old patient hospitalized for management of a Crohn flare complicated by perianal fistulas, status-post loop ileostomy 8 months earlier developed recurrent stomal prolapses to approximately 8 centimeters beginning the third day of hospitalization. Patient was nonchalant about the event and reported that the stoma would prolapse and reduce spontaneously every now and then since the birth of her second child by Caesarean section. The patient also reported being under a significant amount of stress as a result of her chronic condition and believed that might be associated with the prolapse. Manual reduction of the initial prolapse was attempted multiple times and failed. Patient reported a significant amount of pain at the site of prolapse with each attempt at manual reduction. Visual inspection of the stoma revealed no signs of incarceration and stoma functioned appropriately in its prolapsed state. The patient remarked off-hand that the last time an irreducible prolapse occurred, her surgeon recommended putting table sugar on it. A brief search of the literature revealed few case studies supporting the use of table sugar in the reduction of stomal prolapse. Application of approximately 50 packets of granulated table sugar from the hospital cafeteria to the stoma resulted in an immediate (within minutes), observable shrinkage and desiccation of the stoma followed by successful manual reduction.
Discussion
Five case studies have shown success with osmotic reduction of stomal prolapse using table sugar each of which describe almost identical scenarios of prolapses irreducible to manual reduction that either reduced spontaneously or were amenable to manual reduction following application of significant quantities of table sugar (several spoonfuls)5-9. This seemingly well-kept secret requires wider dissemination in the field of general medicine as an additional conservative measure for treating prolapsed stomas in an effort to avoid surgical correction.
References
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- Myers JO, Rothenberger DA. Sugar in the reduction of incarcerated prolapsed bowel. Dis Colon Rectum1991;34:416–18.
- Brandt ARML, Schouten O. Sugar to reduce a prolapsed ileostomy. N Engl J Med 2011;364:1855.[PubMed]
- Flingelstone LJ, Wanendeya N, Plamer BV. Osmotic therapy for acute irreducible stoma prolapse. Br J Surg 1997;84:390.
- Shapiro R, Chin EH, Steinhagen RM. Reduction of an incarcerated, prolapsed ileostomy with the assistance of sugar as a desiccant. Tech Coloptroctol 2010;14:269–71.