Dear Emergency Room Doctor:
This patient has a Barnett Continent Intestinal Reservoir (BCIR) which is a modification of the Kock Pouch continent ileostomy. The entire colon and rectum has been removed, usually for Ulcerative Colitis or Familial Adenomatous Polyposis. (Confirm details with the patient.)
A continent ileostomy means no waste or gas will come out of the stoma until the pouch is intubated (catheterized). Patients with a BCIR or Kock pouch drain their pouch several times daily. It is easy to maintain continuous drainage for this internal ileostomy pouch: insert a 28French Foley catheter (Do Not Inflate the Balloon to prevent damage to the nipple valve continence mechanism),connect to a gravity drainage bag or suction, tape the catheter to the patient’s skin and apply dry gauze over the stoma where the tube enters. The tube should be flushed with 20cc normal saline q3hrs and prn clogging of the catheter.
Pouchitis is manifested by crampy abdominal pain and high volume, watery pouch output. It can lead to dehydration and electrolyte abnormalities. Treatment is with ORAL antibiotics, either Flagyl, Cipro, or Clindamycin, or a combination of Cipro + Flagyl or Cipro + Clindamycin. Prompt response is to be expected, with resolution of cramping and thicker effluent.
Small bowel obstruction (usually related to adhesions, but occasionally from undigested foods), is treated like every other patient including IVs, NG tube for emesis, etc. Inserting an indwelling pouch catheter (see above) will allow for monitoring the resolution of the obstruction, and to help the Radiologist interpret CT scans of abdomen and pelvis in these patients.
INABILITY TO CATHETERIZE
A patient may on occasion be unable to insert their intubation catheter. This results in a functional bowel obstruction. Various size catheters, from the usual 30Fr silicone continent ileostomy catheter to Foley catheters from 28Fr – 24Fr and smaller, can be tried, but the intestinal waste will not drain well through a small catheter. If completely unable to insert a catheter, 2 options exist: Fluoroscopy with a Radiologist introducing a catheter over a flexible guide wire or small catheter, or Endoscopy of the pouch by a Gastroenterologist (this does not require anesthesia or sedation in most patients) to see the channel that leads from the stoma to the pouch and to then insert a catheter.