Editor's Mail Bag

Guest Editors:
Barbara Wendland, RPDt - Dietitian
Karen Witkowski, RN - Enterostomal Therapist
Zane Cohen, MD - Department of Surgery

Before I had my large bowel removed, I was constipated and ate lots of fibre. I kept forgetting to drink enough water and often ended up feeling bloated. Now, I can't eat too much raw fruit and vegetables or my bowel movements are loose. Can you suggest some other foods with fibre and how much I need to balance my diet? I still have my rectum.

Begin by introducing more easily dissolved fibre such as oatmeal, oat bran, barley, and tapioca. Oat products can be found in cereals, breads, and muffins. You can also incorporate them into ground meats, stews and casseroles. Barley goes well in soups and stews. Tapioca can be used in desserts as a thickening agent.

Fruits known to promote stool thickening are applesauce and bananas. Many raw vegetables and fruits are not well tolerated but are frequently easier to digest if cooked or stewed. As well, soups prepared from a variety of vegetables will provide essential minerals and vitamins from natural sources. You might also try juices prepared from vegetables or fruits.

Is it true that certain foods can trigger more bowel movements? Since my pelvic pouch surgery, I have bowel problems after too much sugar, coffee, and tomato juice.

The Pelvic Pouch operation involves the removal of the large intestine and lining of the rectum with the creation of an internal reservoir out of the last part of the small intestine. The average number of bowel movements after this surgery ranges from 4 to 6 movements per day. The specific frequency varies with each individual. Studies on postoperative patients have not pinpointed which foods might consistently be a problem. However, generous portions of simple sugars, i.e. table sugar, honey, jam, or sweets, can cause extra fluid to be drawn towards the sugar in the digestive tract. The result will be rapid transit of the sugars and fluid through the system which, in turn, causes loose movements.

Coffee is a major source of caffeine, a stimulant that increases the motility, or spontaneous movement, of the digestive tract, again resulting in loose bowel movements. Fresh tomatoes are often difficult to digest, particularly the skin. Research studies have not indicated tomato juice intolerance in patients with a pelvic pouch. Increasing the salt content, perhaps adding salt or a small amount of Worcestershire sauce, might help with digestibility.

How much fat does the Canadian Cancer Society recommend and is that the same as calories? I heard that there is a connection between fat and bowel cancer.

It is suggested that 30% of total daily calories should come from dietary fat. North Americans tend to generally consume 40 to 45% of their total calories from foods that are rich in fat content.

Major food sources of fat are dairy products not skimmed of fat; red meat which is not lean; bread/biscuits which are greasy (for example, croissants, doughnuts, muffins, iced carrot cake); and fats/oils (for example, butter, dressing, nuts). Fat intake, along with many other factors, has been linked to colon cancer. Reducing the daily intake of dietary fat will be a positive action in balancing your nutritional intake.

What is a food blockage and what can I do if I get one?

A food blockage is an accumulation of food particles in the intestine that are not digested and, therefore, are not passed through the ileostomy. With a food blockage, one or more of the following conditions may occur:

• Your stool may change from semiformed to liquid.
• The amount of stool may increase.
• Your ileostomy may function almost continuously.
• The stool may have a noticeable odour.
• You may have stomach cramps or pain.
• Your stomach may be bloated or feel full.
• You may feel sick or may vomit.
• Eventually you may not pass stool.

If you feel you have a food blockage:

• Relax
• Lie down
• Assume a knee-chest position
• Massage your stomach
• Take a hot bath
• Drink something warm

If these measures do not work, notify your doctor or go to the Emergency Department of your local hospital. A food blockage can be relieved quite easily by inserting a soft rubber tube into the stoma, or surgically created opening in the abdomen for the drainage of body wastes. The blockage may be flushed out with a saltwater solution.

Since my rectum was removed, I have had three food blockages with my ileostomy. Now I am afraid to eat anything which is not easy to digest. Can you help?

Rule #1 - All food that is consumed should be chewed well.

Rule #2 - Do not rush mealtimes. Allow time to eat at a moderate pace, enjoying the flavour and texture of your food.

Foods which will not cause obstruction are:

• Dairy products/substitute
• Meats, fish, poultry, eggs
• Breads and cereals without nuts or seeds
• Fats and oils used to flavor foods

Foods which might cause obstruction are from the vegetable and fruit groups. In particular, foods rich in insoluble fibre should be avoided at first: corn; nuts; spinach; cabbage; broccoli; cauliflower; and raw fruit/vegetables with skins, membranes, and seeds.

Plan meals around the foods you know will not cause an obstruction, using vegetable juices or soups or soft-cooked vegetables (for example, potatoes or squash) until your confidence increases. Fruits should be very soft such as ripe bananas or applesauce. As your confidence builds, more choices of fruits and vegetables should be introduced.

The skin around the opening of my ileostomy is very sore. I've tried different powders but nothing seems to work. Help!

There are many reasons why skin around the stoma can become sore and irritated. For example, it may be due to sensitivity to the materials in the appliance. There may be too large an opening in the appliance, allowing stool to leak underneath. Another cause may be leaving the appliance in place longer than the suggested time of 5 days. It is important to realize that irritated skin is not normal nor to be expected. A qualified nurse or doctor can help correct this problem.

I love to swim but I've been afraid my appliance will leak in the water. Can you suggest a safe method to try?

Today's appliances are very safe to use in the water. Some people feel more secure when they take waterproof tape and "picture-frame" the edges of their appliance. You may also find that you need to change your appliance more than once a week if you spend a lot of time in the water.

My husband and I would like to have a child. My surgery was done one year ago for familial polyposis. Is it dangerous to become pregnant with an ileostomy?

It is not dangerous to become pregnant with an ileostomy. Since you did not have bowel surgery, you may be more susceptible to a bowel blockage or obstruction. Signs of a bowel blockage include decreased stool output or no stool. You may also experience abdominal pain or cramping. A feeling of fullness, nausea, or vomiting may occur. As your belly changes in size and shape with the pregnancy, so too will your STOMA or opening. For this reason, a change in your appliance or stoma may be necessary.

I've developed small bumps on my stoma. Are these polyps? What should I do?

Small bumps on the surface of your stoma could be one of several things, the most common being scar tissue. This is caused by the spread of blood vessels which form granular-appearing buds during the healing process after surgery. Scarring can occur around the edge of the stoma where the intestinal lining and skin edge are separated by a small gap, this will fill in with scar tissue. Sometimes, inflammatory polyps or adenomas can form on the stoma. These require biopsy and examination under the microscope to determine whether further treatment is needed. These bumps can be removed by electrocautery using an electrical current through a wire loop of a scope and does not hurt since the stoma is almost completely insensitive to pain. Patients should have an annual examination of their ileostomy.

My mother has FAP and I have been talking with a genetic counsellor about taking a blood test to see if I have the FAP gene. She mentioned a new test to look for this gene. Can you explain how it works?

The clinical laboratory plays an important role in the detection of changes in the gene that leads to FAP. Though the laboratory and the patient rarely see each other, it is here that a variety of tests are performed to assess those people who are at risk for FAP. Testing begins with a relatively simple and noninvasive procedure - collection of a blood sample. Our blood contains certain types of cells such as white blood cells. All our cells have various components. Once the cells are separated from the blood sample, different tests can be performed on the components, such as genes, which act as our blueprint for life. Genes tell the cell to make proteins. The job of proteins is to keep the cell normal.

Think of a group of cells communicating with each other through Morse code. Inside each cell, our genes are packaged into DNA which is the code for protein. This code is transmitted as a message. The message is decoded by the receiver to produce the protein. However, when there is a bad connection, or a change in the DNA code, the full message does not get through. This results in a shortened or abnormal protein. Since the message is incomplete, the cell does not know how to act and begins to do things it is not supposed to do.

In our DNA testing laboratory, a new test has been developed to find these imperfect messages or proteins. The chances of finding mutations, or changes in the DNA code, are improved using this technology. In FAP, the damaged gene produces shortened proteins in the majority of patients, with or without a family history of the disease. Previous testing required more than one affected family member. This is sometimes difficult if family members are not available or if only one person in the family has FAP. Since a different technique is being used to test for these proteins, a new blood sample is needed. It is important to remember that a combination of tests may be used to determine individual risk for FAP. As we find out more about the genetic changes that lead to FAP, we can look forward to the laboratory contributing to preventive care for affected families.

Last year, I had an ileostomy after my rectum was removed for cancer. Since the operation, I developed a hernia around my stoma. Why did this happen?

Sometimes, after bowel surgery, a weakness in the abdominal muscles may cause a portion of the remaining bowel to break through. This can create pressure on the STOMA, or opening between the bowel and the surface of the body. One reason may be incomplete healing of the muscles. Another factor may be heavy lifting or straining. If the hernia is creating discomfort after eating or particular activity, minor surgery may be suggested to repair the defect.