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Volume 32, Number 8 May, 2005
GOODBYE GoLYTELY!!
By: Barb Barrickman, RN BSN CWOCN
Are you planning on having a colonoscopy soon? We all know that this is an important screening examination to detect any abnormalities in the colon which could lead to cancer. It is highly recommended that anyone age 50 and over have a colonoscopy, with follow-up colonoscopies on a schedule determined by the results of the first exam and the person’s medical history. The procedure itself isn’t usually a problem. We usually don’t remember that part. It is the preparation for the procedure that really sticks in our minds!
The usual preparation includes a clear liquid diet for at least 24 to 48 hours prior to the procedure as well as taking a preparation to clean the bowel thoroughly. Often, this is GoLYTELY. This preparation produces diarrhea, which rapidly cleans the bowel, usually within four hours. It has proven to be very
effective in cleaning the bowel. The problem with it is the amount that needs to be consumed and the taste. Although it is available in flavors now, it still involves drinking eight-ounce glasses every ten minutes until you get the recommended amounts down. Approximately 50 percent of people taking the preparation will experience some common side effects including nausea, abdominal fullness, bloating, and cramping.
One alternative to GoLYTELY is magnesium citrate liquid. This is usually a ginger-lemon preparation that is mixed with a small amount of water. It is taken in two doses. Although it is a much smaller amount of liquid, it does not taste good and is difficult for some people to drink at all.
Finally, there is a new product that is in pharmacies now. It is called Visicol. This medication is in pill form. No more drinking endless gallons of fluid! It does mean taking 40 pills, however. The usual routine starts the day before the procedure. That day, you take 20 pills within an hour and a half. The pills must be taken with eight ounces of any clear liquid (water, clear carbonated beverage, or clear juice). Then the remaining 20 pills are taken three to five hours before the exam. These are taken in the same manner as before. The directions conclude with this reminder: remain close to toilet facilities.
There are some contraindications for the use of Visicol. If you have congestive heart failure, unstable angina
, unstable angina pectoris, or kidney disease, it should not be used. All of the preparations mentioned above should be used with caution in patients with severe ulcerative colitis.
There are also some new products being introduced that might even eliminate the clear liquid diet prior to the examination. There is one company starting to market a meal kit for the day before the examination. It includes shakes, chicken noodle soup, stroganoff, and even potato chips in a special low-residue diet plan, which supposedly cleans out the bowel even more thoroughly.
So, when planning your next colonoscopy, be sure to ask your physician if you can say goodbye to GoLYTELY!
HAVING SKIN PROBLEMS?
Via: Metro MD, & S. Brevard, FL. Ostomy Newsletter
Skin problems are usually caused by improperly fitting pouches, leakage of stool on the skin, hair follicle irritation, perspiration, or the misuse of skin barriers.
An important aspect in preventing skin problems is keeping a seal. To keep a pouch on irritated skin, it is necessary that the skin is dry. When the skin is irritated, it does not remain dry and cannot be dried with a cloth. A basic method of drying the skin includes a warm heat lamp or hair dryer. “Heat lamp” refers to any type of lamp with a maximum 25-watt bulb placed at least one foot away from the stoma and allowed to shine for only 10 minutes. You will find a desk lamp good to use. Cover the stoma with a piece of damp tissue or cloth to prevent a drying effect directly to it.
Never use a sun lamp. This is an ultraviolet light and will burn your skin. If you have had radiation therapy to the skin around your stoma, do not use any lamp or light to dry your skin. A hair dryer of less than 850 watts may be used if there is a cool setting.
If you find you need to purchase any new skin products listed under remedies, it would be advisable first, to call your ET nurse for suggestions. You may be familiar with the use of one or two products from your hospitalization. If you are comfortable using them, go ahead.
Rash can be located under the tape, under the face plate and on any part of the skin where the pouch comes into contact with the skin. A generalized reddish appearance that covers an entire area, similar to a diaper rash, will be seen. It may be caused by a leaking appliance; perspiration, allergies to tape or hair follicle irritation.
To remedy, use a hair dryer to the skin (low setting); sprinkle a small amount of powder (karaya, stomahesive) on the skin, wipe off the excess, then blot with a skin sealant to seal the powder to the skin. Make sure it’s dry before applying the faceplate. Wearing a pouch belt too tight may also break the seal. If the rash does not clear up in two to three days, consult an ET nurse.
Ulcerated areas can appear anywhere on the stoma because the stoma opening of the pouch was too small and/or activities were causing the faceplate to rub or cut into the stoma.
To remedy, enlarge the size of the pouch opening. (The opening should be at least 1/8 inch larger than the stoma.) Evaluate your activities; you may need a different size or shaped face plate; loosen your belt; if too tight, the belt may cause the face plate to press into the stoma. If this does not help in clearing up the ulcerations around the stoma in two to three days, consult an ET nurse.
Infected or irritated hair follicles under the face plate, raised red areas (similar to acne) at the shaft of the hair follicle, are caused by not keeping the area under the faceplate shaved. To remedy this, you must let the irritation improve before removing anymore hair by shaving or cutting. Use a hair dryer and/or very low heat lamp to dry the skin if oozing is present Use a skin barrier between skin and pouch adhesive until irritation improves. If irritation doesn’t clear in two to three days, consult your ET nurse.
Weeping skin can prevent a pouch or a skin barrier from adhering to the skin for long periods. If your skin is severely irritated and weeping, it may be necessary to change your pouch more frequently to prevent leaking and further damage.
DEALING WITH SKIN ULCERS
Via: Rock County, WI Chapter & GB News Review
Persons with ostomies might experience some form of skin breakdown from time to time. But “skin ulcers”, which are very painful, are not common. A skin ulcer is an open wound; it can be close to the stoma or an inch or more beyond the base of the stoma.
Many people who have experienced skin ulcers are under the impression that they are caused by the cement or seal which keeps the appliance adhered to the body. Up until now, we have never found this to be true.
All cases of skin ulcers that we have seen have been due to:
Belts worn either too loosely or too tightly.
Belts moving away from the original position or slipping.
A poor fitting appliance disc.
Although skin ulcers are not dangerous, they are painful. If they are neglected they can take more than two weeks to clear up.
If you are having problems with skin ulcers, see your doctor or ET nurse to find the cause and cure as quickly as possible.
ILEOSTOMY ABSORPTION CONCERNS
Via: Marshfield, WI, Chipewa Valley, WI & S. Brevard, FL
Due to the absence of the colon and often altered transit time through the small intestine, the type of medication taken must be carefully considered when prescribing for the person with an ileostomy. Medications in the form of coated tablets or time-release capsules may not be absorbed and therefore no benefit received. A large number of medications are prepared in this way. Before the prescription is written, the patient with an ileostomy should inform the physician of his concern. If the medication required is available only in a certain form and the coating would not be destroyed by stomach juices, then the tablet may be crushed between two spoons and taken with water. This often results in an evil-tasting mixture, but absorption is ensured.
The best type of medication for the person with an ileostomy is either in the form of uncoated tablets or in liquid form. Although these are not the most palatable treatments, these dosage forms ensure that the medication prescribed will be absorbed. A pharmacist can assist in choosing the form of a medication that will be best absorbed.
After ileostomy surgery, never take laxatives. For a person who has an ileostomy, taking laxatives can cause severe fluid and electrolyte imbalance.
Transit time through the digestive system varies with individuals. If food passes through undigested, be aware that this may be a sign that nutrients are not being absorbed properly. Prolonged incidents of decreased absorption may lead to various nutritional deficiencies.
ORIGINS OF OSTOMY SURGERY
Keryln Carville RN BSc(Nsg) STN, Silver Chain Nursing Association, Perth, Western Australia
"And Ehud put forth his left hand, and took the dagger from his right thigh and thrust it into his belly. And the haft also went in after the blade: and the fat closed upon the blade, so that he could not draw the dagger out of his belly: and the dirt came out" Judges 3:21-22 (King James Version). Ehud's mortal attack on King Eglon of Moab appears to be the first recorded observation of a traumatic opening into the bowel.
The origins of ostomy surgery are entrenched in the antiquity of surgery. The earliest reports of openings into the gastrointestinal system described rupture or perforation as a result of trauma rather than surgery. This is not difficult to comprehend when one considers the history of violence and wars that has accompanied man's journey down through the ages.
Hippocrates 460-377BC
It is appropriate that the word 'stoma' has its origins in the ancient Greek language for they were often at war and appeared to have had considerable experience in perforating injuries of the abdomen. Ancient Greek physicians such as Hippocrates (460 - 377BC) and Celsus (53BC - 7AD) wrote that wounds of the large intestine were not deadly, where as wounds of the small intestine and bladder were (Richardson 1973).
Another ancient medical figure was Galen (130 - 200AD), who was surgeon to the Emperor Marcus Aurelius and the Roman gladiators, and one presumes very experienced in traumatic perforations of the abdomen. In his prolific writings he discussed surgical management of the large intestine and abdominal wall following penetrating injuries, however, he believed little could be done to save the person with a rupture of the small intestine (Haeger 1989).
Throughout the ages, military surgeons have been presented with great challenges in caring for traumatic wounds. These challenges were exacerbated from the 14th century onwards, for it was in 1346 at Crecy that artillery was first used in battle (Leavesley 1996). Those that survived traumatic injuries to the abdomen, it seems, did so largely as a result of human endurance rather than on account of surgical skill. Cromar (1968) reported that a soldier, George Deppe, who was wounded at Ramillies in 1706 lived for 14 years with what appeared to be a severely prolapsed double-barreled colostomy.
Acute bowel obstructions and perforations occurred not only within the realm of the military but royalty has been sorely effected. King Stephen of England died in 1154 with what was termed "iliac passion", a Saxon term described in 923AD as: "a disorder in which a desire cometh upon a sick man for discharging his bowels, and he is not able, when he is out in the outhouse" (Brooke 1980, p1). The first recorded royal, though not the last, who had an ostomy was Queen Caroline, wife of George II, who died in 1736 from a strangulated umbilical hernia. She endured 7 days of suffering before her gut ruptured, but alas to no avail, for she died 3 days later (Leavesley 1996).
William Cheselden (1688-1752), a British surgeon, had a 73 year old patient, Margaret White, who ruptured her abdominal wall following severe vomiting. Cheselden removed the gangrenous portion of prolapsed gut and left the sound portion, thought to be small intestine, hanging through her umbilicus (Richardson 1973). Although she lived for some years we are left to ponder how she may have managed her ostomy.
Surgeons of that period were reluctant to operate on the bowel for fear of peritonitis and inevitable death to the patient. This was not only harmful to a surgeon's reputation but the major stimulus for what is considered today, some bizarre medical practices. These included purging with laxatives and enemas, attempted dilatation via the anus, blood-letting and the consumption of large amounts of mercury in the hope that the heavy weight of the substance would push through the obstruction. Death due to mercury poisoning ws a common side-effect (Leach 1986). Thomas Sydenham, a noted London physician during the mid-1800's, recommended horseback riding as a means to assist the passage of stool through obstructed gut and his treatment for paralytic ileus was to keep a kitten on the distended abdomen, presumably for the warmth (Leavesley 1996). Failed treatments such as these usually resulted in the death of the patient.
Read More
LACTOSE INTOLERANCE
By: Dorothy Vaillancourt, RN, CETN,
Many people are bothered by this problem, some to mild degree, others to a great degree, and still others who may even become incapacitated by it.
What is Lactose Intolerance?
Lactose intolerance develops when the body has difficulty digesting whole and skim milk and other dairy products. Lactose is a milk sugar and like most sugars, it is broken down by enzymes in the intestinal tract so it can be absorbed as an energy source. The enzyme that breaks down lactose is ‘lactase’. When the intestine does not contain lactase, then lactose
intolerance can occur.
Who has lactose intolerance?
Infants and children have the enzyme lactase so they can digest mother’s milk. However, lactase begins to disappear in many people. Some ethnic groups are more likely to develop lactose intolerance. Seventy-five percent of African-Americans, Jewish, Native Americans, Mexicans, and 90 percent of Asians are apt to develop the condition.
When undigested lactose reaches the colon, it is broken apart by bacteria. Lactic acid and other acidic chemicals result. It’s these products that create the symptoms of lactose intolerance. The symptoms include nausea, abdominal cramps, rumbling, bloating, rectal gas and diarrhea. They usually occur 30 minutes to two hours after eating lactose-containing foods. The severity of symptoms usually depends on the amount of lactose ingested and how much of the enzyme lactose remains in the intestinal tract.
Diagnostic Tests;
To make a definitive diagnosis, one of several tests may be needed:
* Lactose Tolerance Test: A test dose of lactose is ingested and blood sugar determinations are made over several hours. If no lactose is present, the blood sugar does not change.
* Hydrogen Breath Test: When lactose is broken down by the colon’s bacteria, hydrogen is released which then passes out through the lungs. The amount of hydrogen after a lactose meal can indicate a problem.
* Stool Acidity Test: When lactose breaks down to lactic and other acids in the colon, the resulting acidity can be detected by a simple measurement of stool acidity.
* The Home Do-It-Yourself Test: You may want to do a test of your own at home. First avoid milk and lactose-containing foods for several days. Then on a free morning, such as Saturday, drink two large glasses of skim or low-fat milk (14 oz). If symptoms develop within four hours, the diagnosis of lactose intolerance is fairly certain.
Treatment:
Therapy is dependent on whether a patient is willing to tolerate the symptoms. If the symptoms are mild, just avoiding large amounts of dairy products may be enough. If symptoms are more intolerable, there are two options.
First, all food should be carefully checked for lactose. This can be a chore and you may have to be quite a detective, since foods such as bread, bakery goods, cereals, instant potatoes, soups, lunch meats, salad dressings, pancakes, biscuits, cookies and candy may contain hidden lactose. Even prescription and over-the-counter drugs may contain lactose. You must become a label reader, looking for and avoiding milk and lactose.
Buying products, such as milk, which have had the enzyme added to them and buying over-the- counter lactose tablets that can be taken with meals to replace the enzyme the body no longer has, is a good way of controlling symptoms.
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