Gastrointestinal Disorders

Pearls of Wisdom: Getting the Genie Back Into the Bottle…and Other Magic

Case: Arnold, a 67-year-old man, had an ileosteomy performed a little over 2 years ago. He had not encountered any difficulty in management of the ileostomy until today, when it became prolapsed. He has tried manual manipulation, but has been unable to restore the prolapsed tissue to its proper site.

Which treatment might help restore proper anatomical positioning of the prolapsed tissue?

  1. Locally injected hydrocortisone
  2. Systemic steroids
  3. Topical table sucrose
  4. Parenteral diphenhydramine

What advice would you give?

(Answer and discussion on next page)

Louis Kuritzky. MD, has been involved in medical education since the 1970s. Drawing upon years of clinical experience, he has crafted each year for almost 3 decades a collection of items that are often underappreciated by clinicians, yet important for patients. His “Pearls of Wisdom” as we like to call them, have been shared with primary care physicians annually in an educational presentation entitled 5TIWIKLY (“5 Things I Wish I Knew Last Year”…. or the grammatically correct, “5 Things I Wish I’d Known Last Year”).

Now, for the first time, Dr Kuritzky is sharing with the Consultant360 audience. Sign up today to receive new advice each week.

 

Answer: Topical table sucrose

Several years ago, my son gave me a book entitled “Worst Case Scenario.” It contains a wealth of practical suggestions about dreadful things that will, in all likelihood, never happen to you. But they did happen to someone—and if next time it happens to you—you might do well to be prepared in advance.

The scenarios described include your car going off a bridge into a river, getting your scarf caught in the grating of an escalator that is progressively tightening around your neck, and being chased by an alligator. Note: In the case of an alligator chase, run a zig-zag path. Alligators are quick while running straight ahead, but cannot change direction rapidly. Having not yet had the occasion to be pursued by an alligator, I cannot attest to the merit or lack thereof of this method.

Today’s pearl of wisdom can certainly be considered a “Worst Case Scenario.” This case study from New England Journal of Medicine1 provides us with visual as well as written-word proof of concept.

Prolapsed Ileostomy

Keep in mind, this patient was not a novice in relationship to his ileostomy. He is described as having managed it without similar difficulty for over 2 years. So the prolapse need not imply ileostomy mismanagement.

Figure 1. Prolapsed ileostomy.1

When the patient presented for care (Figure 1), the wise clinician simply took advantage of a common observation many of us made in childhood. Remember when you would hold a sugar cube above a cup of tea—and the sugar would soak the tea right up. 

Figure 2. Mary Poppins Rx1

Using the same premise (Figure 2), a simple application of table sugar provided prompt relief of the marked swelling, such that restoration of the ileostomy to its appropriate anatomical position was effected within 2 minutes (Figure 3)!

Figure 3. Prolapsed ileostomy - Success1

In addressing several large audiences about this topic, ostomy technicians within the audience corroborate the success of this method, though I have yet to try it myself.

Seeing the results of this makes me wonder: Is it worth trying the same maneuver when patients present with prolapsed thrombosed external hemorrhoids but are reluctant to undergo local incision and clot extrusion?

What’s the “Take Home?”

Hopefully, scenarios like ileostomy prolapse will remain uncommon. In the event you encounter ileostomy prolapse, a spoon full of sugar might be just the right thing to get the genie back into the bottle. Now about that alligator…

Reference:

1. Brandt ARML, Schouten O. Sugar to reduce a prolapsed ileostomy. N Eng J Med. 2011;364(19):1859.