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Stoma examination DR AMY ROSS (FY2)OSCE EXAMINATION – hints and tips INSPECTION PALPATION Types of stoma QUESTIONS REVISIONcolorectal surgical proceduresifferent Be confident, try and gain experience seeing patients on the ward with stoma’s OSCE: hints and tips Know the different types of stoma Understand the management for bowel obstructionOSCE CHECK LIST - https://geekymedics.com/wp-content/uploads/2020/09/OSCE-Checklist- Stoma-Examination.pdfIntroduction 1. Wash hands 2. Introduce yourself to the patient 3. Confirm the patient’s name and date of birth. 4. Briefly explain what the examination will involve 5. Gain consent 6. Position the patient, usually seated and with hands on pillow Important - ** ask patient if they are in any pain prior to examining INSPECTION General Inspection - ?comfortable at rest, well/unwell, ?signs of dehydration Abdomen - ?any signs of obstruction ? Scars from any previous surgery can remove their stoma bag).ite (ideally should ask patient if they Observe for potential common complications of a stoma: Parastomal hernia (common with colostomies) Prolapse Retraction, Infarction (stoma is turning jet black). ulceration, or fistulation.for any evidence of erythema,PALP A TION tendernessl around the stoma site for any impulse for any obvious parastomal herniaough stenosis and check patencyto assess for anyEXAMINA TION OF STOMA Stoma – surgically created opening into a hollow organ Site If situated in the left iliac fossa  colostomy If situated in the right iliac fossa  ileostomy Spout A spouted stoma will be an ileostomy (or urostomy) as small bowel contents are an irritant to the skin, whereas a stoma flush with the skin will be a colostomy. Consistency Colostomy output is generally thick and sludgy (like faeces), whereas an ileostomy is Number of lumens often greener. A urostomy will produce urine. Loop stomas will have two lumens, whilst end stomas will have one lumen. Colostomy End colostomy (sigmoid/descending colon) removed or stapled off or oversewnsurface + distal bowel Uses include: tumours (all distal bowel removed so permanent colostomyal required) Hartmann’s procedure for emergency resection of rectosigmoid lesons where primary anastomosis unfavourable Colostomy Loop colostomy (transverse/descending colon) Two openings made in loop of intact bowel Brought through one incision to form a stoma performed to divert faecal stream away from distal bowel because of: Obstructed large bowel Colonic lesions  where pt may not survive extensive surgery but still maintains certain quality of life (contained tumour perforations or fistulae) Distal bowel resection with primary anastomosis (to protect anastomosis while sutures heal/reversed after approx. 6/52 (however loop ileostomies more commonly performed for this).Colostomy Double barrel colostomy (transverse/descending colon) A segment of bowel is removed and both ends are brought to the surface SEPARATELY to form a stoma. Proximal end drains faeces Distal end (mucous fistula) can drain mucous from non-functioning bowel. Used infrequently after a segment of colon removed and primary anastomosis unfavourable.Ileostomy End Ileostomy (terminal ileum)  when part of colon is removed (or needs to rest) and the end of small bowel brought to the surface  can be temporary or permanent.  may be created for subtotal colectomies (e.g. toxic megacolon, ischaemic bowel and synchronous tumours) Ileostomy Loop ileostomy (distal ileum)  Commonly used to protect ileonanal or low colorectal anastomoses OR prevent stool passing through anorectum (e.g. perianal crohn’s disease, anorectal trauma or malignancy).Urostomy - short segment of ileum removed to act as bladder - one end sutured to skin - other end sutured to ureters - replaces bladder after cystectomy (e.g. for bladder carcinoma) EARLY - High output stoma >1L/day (dehydration and hypokalaemia) - Retraction - Bowel obstruction/ileus - Ischaemia of stoma COMPLICATIONS OF STOMA’S LATE - Parastomal hernia - Prolapse - Fistulae - Stenosis - Psychological complications - Skin dermatitis - MalnutritionSTOMA CARE Stoma nurse support Some bags are single use and are changed when full Bags can be left on in the shower Some bags have an emptying tap – emptied when 2/3rds full, irrigated with water everyday and changed approx. every 2-4 days FOODS that can cause blockage – nuts, sweetcorn, mushrooms, dried fruits FOODS that cause diarrhoea – fruit juice, vegetables, coffee, alcoholGENERAL P AST APER QQuestion 1 A 56-year-old patient is brought into the emergency department via ambulance after a road traffic collision. His hip appears to be in flexion, abduction, and external rotation. He has a pelvic x-ray which shows the right femoral head appearing larger than the left femoral head and the right femoral head appearing medial to the acetabulum. There is no fracture noted and no overlying skin lesions to the site. Closed reduction is performed with traction when the patient is adequately sedated. He is reviewed several hours later by the physiotherapy team and it is noted that he is unable to adduct his thigh. Which is the most likely nerve that has been damaged? A – Femoral nerve B – Superior gluteal nerve C – Obturator nerve D – Inferior gluteal nerve E – Lateral femoral cutaneous nerveQuestion 2 wound. She is haemodynamically unstable, with an ultrasound scan showing free fluid in the pelvis, and is taken to theatre for an emergency laparotomy. During surgery, the surgeons find that the patient has suffered a single large incision through the broad ligament. Given the location of the incision, which structure has likely been damaged? A- Cervix B- Fallopian tubes C- Ovarian vessels D- Renal artery E- Uterine vesselsQuestion 3 16-year-old girl develops pyelonephritis and is admitted in a state of septic shock. Which one of the following is not typically seen in this condition? A – increased cardiac output B – increased systemic vascular resistance C – Oliguria may occur D – Systemic cytokine release E – TachycardiaQuestion 4 A 40-year-old woman presents with right-sided abdomen pain. The pain is sharp in nature and it comes and goes. She notices that the pain is usually triggered by consuming fatty food. She is diagnosed with biliary colic. The secretion of what hormone is the most likely cause of her symptoms? A – Cholecystokinin B – Secretin C – Gastrin D – Somatostatin E- Vasoactive intestinal peptideIn this scenario, the patient has biliary colic. Right-sided abdominal pain after consuming fatty food is a commonly seen presentation. Gallstones are formed inside the gall bladder and Cholecystokinin (CCK) is responsible for gallbladder contraction. After consuming fatty food, CCK is released and encourages gallbladder contraction, which then leads to abdominal pain if gallstones are present.Question 5 chest pain. She is diagnosed with community-acquired pneumonia and given oral doxycycline and co- amoxiclav. On day 5 of antimicrobial treatment, her chest symptoms have improved but she starts having diarrhoea. Her stool culture showed Clostridium difficile positive. This is the first time she has had Clostridium difficile infection. What is the first-line treatment? A - IV co-amoxiclav B -IV metronidazole C - IV vancomycin D - Oral fidaxomicin E - Oral vancomycinQuestion 6 cast over the proximal aspect of the knee for three weeks. The patient is now complaining offitting numbness over the lateral two-thirds of the outer leg. The foundation doctor performs a lower limb neurological examination and suspects common-fibular nerve injury. The function of which muscle is likely to be spared in this patient? A - Biceps femoris B - Extensor digitorum longus C - Extensor hallucis longus D - Fibularis tertius E - Tibialis anteriorThe biceps femoris muscle has two heads. The short head is innervated by the common peroneal division of the sciatic and the long head by the tibial branch of the sciatic nerve. Therefore, the biceps femoris will still be able to perform flexion of the knee. Extensor digitorum longus is innervated by the deep fibular nerve- a branch of the common fibular nerve. This may cause the patient to present with weakness of toe extension. Extensor hallucis longus is innervated by the deep fibular nerve- a branch of the common fibular nerve. This may cause the patient to present with weakness of big-toe extension. Fibularis tertius is innervated by the deep fibular nerve - a branch of the common fibular nerve. This muscle acts to evert the foot- a movement important in the gait (walking) cycle. Tibialis anterior is innervated by the deep fibular nerve- a branch of the common fibular nerve. This muscle is important for dorsiflexion of the foot. Therefore dysfunction of this muscle will present clinically with foot-drop.Question 7 A 55-year-old man is due to undergo a radical prostatectomy for carcinoma of the prostate gland. Which one of the following vessels directly supplies the prostate? A - External iliac artery B - Common iliac artery C - Internal iliac artery D - Inferior vesical artery E - None of the aboveThe arterial supply to the prostate gland is from the inferior vesical artery, it is a branch of the prostatovesical artery. The prostatovesical artery usually arises from the internal pudendal and inferior gluteal arterial branches of the internal iliac artery.Question 8 ask the patient to flex their fingers at the distal interphalangeal joints. orthopaedic clinic. You The action of which muscle is being assessed here? A - Flexor digitorum longus B - Flexor digitorum profundus C - Flexor digitorum superficialis D - Flexor hallucis longus E - Flexor pollicis longusFlexor digitorum profundus is responsible for flexing the distal interphalangeal jointQuestion 9 A 46-year-old man undergoes a partial thyroidectomy. When he returns to the ward, he reports a hoarse voice. You are aware that this is one of the complications of thyroid surgery. Which of the following nerves is most likely to be the cause of the patient's symptoms? A - Greater auricular nerve B - Internal branch of the superior laryngeal nerve C - Transverse cervical nerve D - Recurrent laryngeal nerve E - Phrenic nerveThe recurrent laryngeal nerve arises from the vagus nerve (CN X). It carries motor supply to all but one of the laryngeal muscles, as well as sensory supply to the larynx below the vocal cords. Dysfunction of either recurrent laryngeal nerve produces a hoarse voice, as seen in the patient in the question. The only other nerve in the above options to innervate the larynx is the internal branch of the superior laryngeal nerve. This is one of two branches of the superior laryngeal nerve, which, like the recurrent laryngeal nerve, also arises from the vagus nerve. The internal branch of the superior laryngeal nerve carries sensory supply to the larynx above the vocal cords. The external branch carries motor fibres to the cricothyroid muscle, the only laryngeal muscle not supplied by the recurrent laryngeal nerve.Question 10 A 19-year-old man is seen in the gastroenterology clinic with a 4-month history of abdominal pain and diarrhoea. In the last month, he has noticed that he has been passing fresh red blood in his stool and is having up to 6 bowel movements a day. He is slim and reports having lost 5kg in weight over the last 4 months. He is referred for multiple investigations. Which of the following findings supports the likely diagnosis? A Deep mucosal ulceration B Goblet cell depletion C Granuloma formation D Skip lesions E Transmural inflammationAnswer BQuestion 11 A man undergoes a high anterior resection for carcinoma of the upper rectum. Which one of the following vessels will require ligation? A Superior mesenteric artery B Inferior mesenteric artery C Coeliac axis D Perineal artery E Middle colic arteryThank you! Please complete feedback..References https://teachmesurgery.com/examinations/gastrointestinal/stoma/