Stoma OSCE Examination

1. Introduction
2. General Inspection
3. Inspecting the Stoma: Site
4. Inspecting the Stoma: Spout
5. Inspecting the Stoma: Lumens and Mucosa
6. Inspecting the Output (Effluent)
7. Inspecting the Peristomal Skin
8. Palpation and Auscultation
9. Assessing for Complications
10. Completing the Examination
11. Quiz

Wash your hands and don personal protective equipment (an apron and gloves are appropriate, as a stoma examination involves potential contact with bodily fluids).

Introduce yourself to the patient and ensure to mention your grade e.g. 3rd year medical student/junior doctor/consultant.

Confirm the patient’s details taking 3 points of identification usually; Full name, Date of birth and NHS/Hospital number.

Obtain consent for the examination, ensuring to explain what the examination will entail. Many patients are understandably self-conscious about their stoma, so it is important to be sensitive and to maintain their dignity throughout.

Position the patient lying flat (supine) on the bed with the head supported by a single pillow, as this best exposes the abdomen and stoma.

Adequately expose the abdomen from the xiphisternum to the pubic symphysis so that the stoma, the appliance and the surrounding skin can all be inspected. Only expose the patient when you are ready to examine.

Ask the patient if they have any pain anywhere before you begin, and whether they have noticed any recent problems with their stoma, such as bleeding, leakage or a change in output.

Begin by standing back and observing the patient from the end of the bed. Assess whether they look comfortable or are in any distress, and note their general nutritional status. A cachectic or visibly unwell patient may point towards an underlying malignancy or inflammatory bowel disease as the reason the stoma was formed.

Look around the bedside for clues. Spare stoma appliances, adhesive removal sprays and barrier creams suggest a well-established stoma and an independent patient. A nasogastric tube, drains or a catheter suggest the patient is in the early post-operative period. The presence of parenteral nutrition (TPN) may indicate a high-output stoma or short-bowel syndrome.

Inspect any surgical scars on the abdomen. A midline laparotomy scar alongside the stoma is common and indicates open abdominal surgery, while smaller laparoscopic port scars suggest a minimally invasive approach.

The site of the stoma is one of the most useful clues to its type, as different parts of the bowel are conventionally brought out in different quadrants of the abdomen.

• A stoma in the left iliac fossa (LIF) is most likely to be a colostomy, as the sigmoid and descending colon sit on the left side of the abdomen.
• A stoma in the right iliac fossa (RIF) is most likely to be an ileostomy (formed from the terminal ileum) or a urostomy (an ileal conduit).

These are conventions rather than absolute rules – the site is interpreted alongside the spout and the output before reaching a conclusion. Note also whether the stoma has been sited away from skin creases, scars and the umbilicus, as poor siting predisposes to leakage and appliance problems.

Image - An ileostomy. Note the protruding spout, which lifts the irritant small-bowel contents away from the surrounding skin

Creative commons source by Salicyna [CC BY-SA 4.0 (https://creativecommons.org/licenses/by-sa/4.0)]

Note whether the stoma is flush with the skin or whether it has a protruding spout. This single feature reliably distinguishes a colostomy from an ileostomy, and the reason behind it is important to understand.

An ileostomy is spouted, typically protruding around 2–3 cm above the skin. Small-bowel content is liquid and rich in digestive enzymes, which would rapidly excoriate and ulcerate the surrounding skin if allowed to sit against it. The spout lifts the output clear of the skin and directs it straight into the appliance, protecting the peristomal skin.

A colostomy is flush with the skin (no spout). The output from the colon is more solid and far less enzyme-rich, so it does not damage the skin in the same way, and a spout is not required.

A urostomy is also spouted, for the same reason as an ileostomy – constant contact of urine with the skin causes maceration and irritation.

Count the number of lumens (openings) visible at the stoma, as this distinguishes an end stoma from a loop stoma.

• A stoma with a single lumen is an end stoma, where the proximal end of the bowel is brought to the surface and the distal bowel has usually been removed or closed off.
• A stoma with two lumens is a loop stoma, where a loop of bowel is brought to the surface and opened, leaving both a functioning (proximal) limb that produces output and a non-functioning (distal) limb. Loop stomas are frequently formed as a temporary measure to defunction and protect a more distal anastomosis or rejoining of the bowel while it heals.

In the early post-operative period a loop stoma may be held in place by a plastic bridge or rod passed under the loop, which stops the bowel retracting into the abdomen before it has adhered. Noting its presence is a useful clue that the stoma is both a loop stoma and relatively recently formed.

Inspect the stoma mucosa itself. A healthy stoma should be pink or red, moist and slightly shiny, reflecting a good blood supply. A dusky, purple or black stoma is a worrying sign of ischaemia and possible necrosis, which may threaten the viability of the bowel. The stoma is normally insensate (it has no somatic pain fibres) and may bleed slightly when touched, which is normal because of its rich superficial vascular supply.

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