Diseases of the colon, stoma, and quality of life
Diseases of the colon, especially neoplastic diseases, are an increasingly discussed topic and the number of people affected by this problem is rising. In European countries, our republic occupies a leading position in the incidence of colorectal carcinoma. Serious diseases of the colon and rectum include ulcerative colitis, Crohn’s disease, diverticulosis, and especially colorectal and rectal carcinoma. In the emergence of ulcerative colitis and Crohn’s disease (which are primary nonspecific bowel inflammations), multiple factors are involved, such as immunological influences of the external environment, infectious factors, and a significant role played by the genetic makeup of an individual. For example, for Crohn’s disease, environmental factors include a low-fiber diet, excess refined sugar, gluten (white bread), smoking, and generally unhealthy lifestyle habits (alcohol, etc.). For diverticulosis, by contrast, diet is an important factor in onset—an inedible-fiber-poor diet strongly promotes disease development. For colorectal and rectal carcinoma, genetic and environmental factors are also decisive. It has also been demonstrated that the incidence of colorectal carcinoma is higher in certain professions where employees come into contact with chemicals (organic solvents, dyes and pigments, asbestos processing). As for genetics, monogenically determined syndromes account for up to 15% of all colon tumors (familial adenomatous polyposis, hereditary nonpolyposis syndromes of colorectal carcinoma). Colorectal carcinoma is currently the third most common malignancy in the world. This is associated with the growing importance of early diagnosis, which is connected with secondary prevention and colorectal cancer screening. Treating patients with already advanced disease, which manifests clinically as an acute abdomen (intestinal obstruction, bowel perforation with peritonitis, or bleeding into the gastrointestinal tract) or even clinical symptomatology of metastases, is very complicated and treatment success is substantially reduced. Because average human lifespan is increasing, age also contributes to the rise in colorectal carcinomas, as the risk of neoplastic diseases increases with longevity.

From an anatomical perspective, the large intestine is the terminal section of the digestive tract. It has the following parts—caecum (coecum), ascending colon (colon ascendens), transverse colon (colon transversum), descending colon (colon descendens), sigmoid colon (colon sigmoideum), and rectum (rectum).

The ascending colon runs along the right side of the abdominal cavity, the transverse colon crosses the abdominal cavity from right to left, the descending colon runs along the left abdominal wall into the left iliac fossa, where via the sigmoid loop it descends into the pelvis, and the whole segment is terminated by the rectum.

Defecation is a reflex process that usually occurs once every 24 hours. With stool accumulation in the rectum, pressure rises, which gives rise to the urge to defecate. Then the rectal sphincters relax and the abdominal muscles and diaphragm contract, increasing pressure on the distal part of the digestive tract, and evacuation occurs. The defecation reflex is controllable by will.1

Stoma is an artificial opening of any hollow organ to the surface of the body. In general, stomas can be divided into derivation stomas, through which something is diverted from the hollow organ—for example, colostomy, ileostomy, tracheostomy, and colostomy. There are also feeding stomas, through which some substance, most often food, is introduced into a hollow organ—for example, percutaneous endoscopic gastrostomy (PEG) or percutaneous endoscopic jejunostomy (PEJ).2

Diseases leading to stoma creation

Among disorders of the gastrointestinal tract in whose treatment a stoma may be created are idiopathic intestinal inflammations—Crohn’s disease and ulcerative colitis, precancerous conditions and neoplastic diseases, ileus states, injuries associated with intestinal perforation and ischemia, and incontinence.3 Colostomies, that is, stomas of the large bowel, are very often established because of an obstruction, most commonly a tumor located in the lower part of the large intestine or rectal area. Inflammatory processes of the bowel, fistulas, congenital defects, bowel wall trauma, and so on, are also common reasons for creating a stoma.

A stoma can be of temporary or permanent character. Colostomies are established in three most typical locations: on the caecum, so-called caecostomy; on the transverse colon, so-called transversostomy; and on the sigmoid loop, so-called sigmoidostomy.

According to shape, three types of colostomy are distinguished: double-barrel colostomy, single-barrel colostomy, and loop (stoma through bowel wall) colostomy.4
Double-barrel, axial colostomy:
the bowel loop is brought out; after final adjustment, two openings remain on the abdominal wall, close to one another, sometimes separated by a small bridge of skin.

Single-barrel, terminal colostomy:
most often a permanent colostomy. It is often created when the lower part of the large bowel is removed.

Wall colostomy:
usually established only temporarily as a form of decompression of bowel contents, most often on the caecum, sometimes also on the transverse colon or sigmoid loop.

Ileostomy:
is usually performed at the terminal part of the small intestine.

History of stomas

The first mentions of stomas appear around 350 BCE—Praxagoras of Cos described techniques for establishing a bowel diversion. Trauma was the reason for creating the stoma. How the patient fared afterward is unknown.

For example, Celsus, who lived from 55 BCE to 7 CE, dealt with the observation of bowel injuries that initially healed by fistula formation, which then closed spontaneously. Another historical record of a stoma was also found in the time of Paracelsus, who recommended that when operating on the bowel, the diversion should be attached to the injured large intestine in a way that avoids unnecessary intervention into the remaining part of the colon.5 Until the 18th century, intestinal obstruction—ileus—was a very common cause of death. The only treatment then in use was laxative therapy. If treatment by this method was not successful, mercury was administered, whose weight was thought to relieve bowel narrowing by its mass.

The first colostomy was performed in 1710 by the French surgeon Littre. His patient was a six-day-old newborn who had no anal opening at all. The child could not be saved. William Cheselden was the first to perform what is called axial transversostomy, on a patient almost 80 years old, who lived for several years after the operation. The first truly planned stoma operation was performed by Pillor in 1776. During the operation, Pillor performed a caecostomy, suturing the stoma into the patient’s skin. In England, the first to perform intestinal surgery was Dr. Luke in 1850, who performed the fixation of an abdominal colostomy, bringing out the sigmoid loop through the abdominal wall. Standardization of surgical methods came only around 1908, when Ernest Miles described the procedure for amputating the rectum. The first person to perform a stoma in Bohemia was physician Karel Maydl.6

Tracheostomy7 is considered one of the oldest surgical procedures, performed already in ancient Egypt roughly 3,500 years before the common era. In 1909, Jackson described a tracheostomy technique still used today, together with its possible complications. A certain alternative to tracheostomy is percutaneous dilational tracheostomy. This method was described by Ciaglia around 1985.

Toward the end of the 20th century, there was a large increase in the number of percutaneous dilational tracheostomies, with a corresponding decrease in surgical tracheostomies.8

Stoma function

The appearance of bowel output via the stoma depends on the location of the colostomy. The closer the colostomy is to the rectum, the firmer and less voluminous the output is, and the less gas it contains. Colostomy at the sigmoid produces output similar to stool. From transversostomy, the output is usually fluid and larger in amount, about 300 to 400 ml in 24 hours. From caecostomy, output is very fluid and similar to small-intestinal content, in an amount of about 500 to 800 ml per day.9

Stoma complications

After creating a stoma, complications may occur, such as peristomal skin irritation, inflammation of tissue around the stoma, bleeding from the stoma, stenosis of the stoma and retraction below skin level, stoma prolapse, and hernia in the stoma region.10 Further significant complications occur in relation to dysfunction of embodiment in the person for whom a colostomy was performed as part of therapeutic care.

Body and embodiment

Western medicine and modes of inquiry, deriving from classical and Eastern roots, are grounded in the claim of modern methodology in the Cartesian tradition.11 By describing individual parts of the body and organ functions, objectification is fulfilled. Yet the body is also a subject, which cannot be captured through physiological, psychological, and biochemical pathways. If science proceeds with more geometrico thinking in the validity of the Cartesian subject-object figure, in medicine we lose insight into the essence of the person, remaining in onticity, which is nevertheless only one part of the whole—being. The human being exists in the temporality of life: in the temporal dimension in which essential past is preserved as part of the present and at the same time unfolds toward the future. The human body has openness to embodiment with the possibility of projecting itself into landscape, world, and being. When the person is ill, it cannot be approached as an object or thing that must be repaired so it functions as before, so it is capable of performance. In illness, the relation of that person to being itself is projected into the whole. The return to the possibility of free movement through time for a powerless person is not achieved only through ontic clarification of discomfort and selection of proper treatment targeting the problematic cell, organ, or system. The body can be viewed in two ways. Through the claim of current medical practice and accepted methodology (a scientifically admissible way of clarifying and presenting findings through measurement and weighing—clare et distincte), we see a body. If we can see the human body in another illumination—non-Cartesian—this “body” has another value; it develops, grows, and reaches into the surrounding world, and its surface is the result of oppositions (external and internal aggression). The result is one’s appearance—the PERAS of our embodiment. In this way, the body has a particular form, and form is linked with FYSIS—with growth. Our embodiment may therefore be understood as the interface between body and non-body. Phenomenology of embodiment grows out of E. Husserl’s phenomenological tradition. Husserl’s questioning, in the context of secularization in European society away from a spiritual toward a material conception of the world, argues that science is not concerned with reality itself, but only with representation of that reality. At first glance, phenomenology, which emerges from this reflection, takes a critical stance toward Cartesian scientific foundations. At the same time, it offers a path leading to a view of the world that is not scientific theory, not an approximation of natural reality. It is the natural world that is co-created and personally lived, including bodily life. Here philosophy enters the philosophy of embodiment. The interface between body and non-body is in constant movement, in dynamics of coming into being and passing away. Phenomenological reflections on body and embodiment call for awareness of this duality—the relating of body both to another world and to one’s own selfhood. The body has its own understanding and is not fixed in concepts; therefore its information is often in direct contradiction with mental information. Sensorially, the body separates from its surroundings.

Philosophy of embodiment

The body is both what we can conceive and what we can see (soma). What we can grasp, clarify by measurement, and weigh is called (sarx). But it is also what we cannot conceive—what is the body penetrated by soul, having expression; this is the ensouled body, called pexis, which gives expression to the entire body. This body has no edges; we cannot objectify it, grasp it, or fully understand it except philosophically.12 Through this ensouled body—pexis—through which we exist, we are what we ourselves are in our mind and through which we embody. Soma (the body’s form), sarx (the body’s content), and pexis (the ensouled body) form a whole—holos. Merleaou-Ponty13 speaks of a holonic order, which forms a non-structural schema without edges (margo), creating one whole by linking mind, will, feeling, and motor function in a single temporal span. Body schema here functions as a background on which individual parts are shown and movement forms emerge. It has two faces—structural, with edges (margo), and non-structural (without margo), and can be understood as BACKGROUND. It is therefore natural to a person that he or she is unaware of this and, when a “smudging” or change occurs (disruption of body schema), that state is experienced as difficulty or inability to move or perform other function. (note: when a stoma is established, there is a very significant intervention in both structural and non-structural body schema; the demand is considerable for the patient on a bio-psycho-social-spiritual level of existence). From a phenomenological perspective, body schema is an arc between re-tences (past) and pro-tences (present), while the background is in-tence (intentionality—the directedness of consciousness toward the world, the essence of consciousness).14 Embodiment can be understood as a specific movement of the body in the unity of soma, sarx, and pexis (structural and non-structural body schema) forward; it is led by the hand toward things around us (horizontality) and further by speech, which draws us into verticality (transcedence). The body is an anchor in the present and must be connected to inner temporal awareness. Embodiment is therefore continuous creation of movement figures that answer the total connectedness of body and surroundings.

Embodiment and stoma

According to Husserl, Patočka, Sartre, and Merleau-Ponty, one’s own body is something that cannot be objectified. To this belongs a special spatiality that gives the body a distinction from other objects. The function of the body is in continuous rooting in the surrounding world, objects, and between them.

In illness, the mode of perception is temporarily or permanently excluded or limited from activity—it is dysaretic.15

(Phenomenological explanation of health and illness: the aretic person—a healthy person exists in natural movement along their life path in openness and possibility, in the realization of their given possibilities. If this is limited or entirely prevented in the habitual sense of movement, dysaretia occurs—illness; the result is the inability to move freely and autonomously along one’s life path in the Heideggerian sense).

A stoma is always a very significant, life-altering intervention for the person in question. It is a process that affects structure—the soma—but its true face appears only through the outer world. This event is a contrast to everything prior, opening awareness of oppositions stretched between health and impairment, and between life and death. A person is forced to think about human fate. Being affected by a stoma and everything this condition brings becomes a daily life reality; new life situations demand another movement through life.

The degree of otherness in a given situation is directly tied to bodily state. It is always directly connected to what emerges and is thematized, and for each person in that situation it is specific and original. It is based on the relation between the person and their environment. Body schema is constantly present in health and illness, without the person necessarily noticing and registering it. People with a stoma are in a strained situation of otherness. Changes occur in the understanding of one’s own self (altered selfhood and self-relation), but also in the understanding of the surrounding world. Bodily change is therefore simultaneously a change in the outer environment. Illness can limit and even make impossible life movement; these are the circumstances in which the body becomes thematized—pain, dysfunction, dysfunction, immobility, etc. It is precisely at this moment that illness is currently thematized, that is, moves to the foreground. The degree of impairment is not decisive, nor is the extent to which the person with a stoma approaches this situation. A significant role is also played by visibility—what is visibly apparent or different from others at first glance. The other’s reaction affects the self-concept of the I.

Psychosomatic understanding of diseases of the colon

All flows of energy in our organism are tightly connected with the psychical component. The psyche is profoundly important for regulating all processes in our body, and its expressions are present at every bodily level. Practically all problems begin in the psyche, because thought is always primary. The theory of the functioning of the limbic system states that the origin of every movement and every activity arises in the limbic system, including emotionality in the sense of thought, which is based on motivation for that activity. Subsequently, the whole chain of control mechanisms starts and influences the effector—the actualization of the possibility of a certain movement (understood habitually, overall). The psyche therefore affects, through energetic flows, mood, the ability to carry out certain activities, speaking, recalling thoughts, etc. When these control mechanisms are disturbed and their origin is in the psychical sphere, certain changes appear in the bodily sphere. Where the “weak link” is located, pathology usually appears first. If a person is sensitive to current bodily otherness and can listen to the language of the body, the first signs of this energetic imbalance are usually detected. If, however, the body’s voice is not heeded, energetic imbalance deepens and, at a certain level of dysbalance, produces warning symptoms (nonspecific), which may gradually become more pronounced and worsen, eventually resulting in a concrete disorder. In the first stage, it manifests as a functional disorder—a dysfunction. This is usually reversible. But when intervention and a change in the cause of illness (thus in psychical regulation) are not provided at this stage, the disease gradually worsens and begins to manifest at the morphological-organic level. Those stages are usually irreversible.

From a holistic medicine perspective, diseases of the colon belong to the upper energy system, represented by the lung-colon pair. Through breathing, the body receives current usable energy; at the level of the lung pathway, energy of the upper system combines with rising gastric and splenic energy (the middle energy system), and together with the basic kidney energy (lower system), forms complex energy available for immediate use and for overall existential possibility of acting in the world (personality orientation). The colon pathway is related to mucosa generally, and in interconnectedness especially to the entire digestive tract, respiratory system, and skin. (note: food allergy reactions very often manifest as a combination of breathing, digestive, and skin difficulties). Pathology in this pathway of the upper energy system manifests as a whole range of difficulties—teeth pain, throat pain, headache, hay fever, asthma, urticaria, constipation, diarrhea, abdominal pain with bloating, general digestive discomfort, and also abdominal and thoracic muscle cramps. Psychological disturbances include depression, apathy, fatigue, and overall restriction of habitual life movement.

The large bowel has a detoxifying role, and when this organ is weakened the organism as a whole is endangered by dysaretia (a disturbance of balance at all organ levels).

Very often in the personality configuration of a person with disrupted colonic function, one can psychotherapeutically see, at the emotional level, sadness and anger. In chronic stubborn disturbances such as constipation, there is a lack of “openness” to the world, clinging, and behaviour hurried by fear or anxiety, similar to a burst pattern, and the body often responds with accelerated intestinal peristalsis—the transport of contents is too fast and water cannot be absorbed. If these states recur frequently (diarrhea and constipation becoming part of everyday life), the bowel is heavily irritated and responds with crampy state (colon irritabilis). Disharmonious peristalsis, together with other microbial conditions, can cause disorders of the intestinal wall, to which inflammation may follow. Very often this condition is complicated by minor erosion—a mucosal defect that gradually changes into an ulcer, and neoplastic growth in the inflammatory site is possible. The way of life of a person experiencing this disorder, including their embodiment, is in such an unfavorable state that the conditions for the disorder are continuously renewed; it stays in constant cycling. The situation ends in a burdensome state, where dependence on sanitary facilities (toilets), that is, urgency when the “intestine” signals, or on obsessive “evacuation” techniques in constipation prevails. The overall tuning is fear and anxiety, uncertainty. These emotions exactly accelerate cardiovascular activity but also affect colonic function.

From a psychological perspective, it should be realized that evacuation is an extremely intimate matter, referring to an area that is made accessible very often only to one person or one’s closest relatives, yet requiring openness and courage, because intimacy and shame-associated anxiety are closely linked.

In surgical treatment of stomas, distress ends only partially. It is true that the autonomic system itself does not initiate responses of internal organs alone, but because of full integration into the complex existential context of human life, the bodily aspect and form of response are mediated. The psyche plays a major role in comfort or discomfort of a person with a stoma, which even the most successful surgery, subsequent care, and education, including available advanced prosthetic aids, cannot fully secure. In the case of a stoma, there is concern not only that a partner or close environment will be confronted with this specific burden, but also fear of rejection of otherness in bodily structural schema. In intimate partnership, full acceptance is needed, and exactly here the major complexity and fear of rejection lie, with the risk of confirming loss of self-respect and self-worth. Loneliness worsens; coexistence with other people becomes more complicated and the basic possibility of intimacy is not fulfilled—the tuning into a shared whole, into I and You in the sense of We, based on trust and essential co-presence. The confirmation of co-presence, and of a free (or non-free) relationship with oneself and with the other significant person, gives rise to intimacy. And intimacy with oneself depends on the ability to accept oneself.

Conclusion

A stoma is a significant intervention into the existence of a person, with deep trauma in the context of embodiment. Opening life in future time in the widest possible way depends on the overall orientation of the patient toward the situation. The biological therapeutic component—in terms of diagnosis, surgery, subsequent wound healing, and possible oncological care—always goes hand in hand with the demand of the psyche. Soma—the form of body, sarx—the content of body, and pexis—the ensouled body in the unity of intervention-therapy are necessary. The path to reintegrating structural and non-structural body schema is difficult but possible. The greatest task for a person with a stoma is self-acceptance. If this is achieved, an entire world opens.

Author: PhDr. Helena Kalábová, Ph.D.
She teaches and publishes at the Department of Social Studies and Special Pedagogy at TU Liberec since 2008 in the areas of ethics, social and pedagogical anthropology, philosophy, phenomenology of health and illness, etiopathy, crisis intervention, individual, family, and couple therapy.
15 years of practice in private psychosomatic disorder treatment.
Literature - text sources

ELIŠKOVÁ, M., NAŇKA, O., 2006. Overview of anatomy. Prague: Karolinum. ISBN 978-80-246-1216-4.
HEIDEGGER, M., 2006. What Is Metaphysics? Prague: OIKOYMENH. ISBN 80-7298-167-6.
HEIDEGGER, M., 2006. Man Dwells Poetically. Prague: OIKOYMENH. ISBN 80-7298-165-X.
HOGENOVÁ, A., 2005. On the Problem of Knowing. Prague: PedF UK. ISBN 80-7290-222-9
HOGENOVÁ, A., 2006. On the Phenomenon of Movement and Thinking. Prague: Eurolex Bohemia. ISBN 80-86861-72-4
KALABOVA, H. 2011. Phenomenology of Health and Illness. Liberec: TUL. ISBM
MARKOVÁ, M., 2006. Stoma of the Gastrointestinal and Urinary Tract. Brno: NCO NZO. ISBN 80-7013-434-8.
MARIŇÁKOVÁ, A. History and current state of care for patients with colostomy. Oncological Care. Prague. ISSN 1241-5602
MERLEAU-PONTY, M., 1998. The Visible and the Invisible. Prague: Oikúmené ISBN 80-7298-098-X
MICHÁLKOVÁ, H., 2010. The issue of meeting the needs of clients with a stoma. České Budějovice. Dissertation. University of South Bohemia. Faculty of Health and Social Sciences. Supervisor: Valérie Tóthová.
NOVÁK, K, ZEMANOVÁ, A. Quality of life of patients. Military Medicine Letters. ISSN O372-7025
PEŠKOVÁ, J., 1991. All on One Stage of the World. Prague: Svoboda. ISBN 80-205-0091-X
PATOČKA, J., 1995. Body, Community, Language, World. Prague: Onyx. ISBN 80-85241-90
SCHWARZ, Pavel, MATOUŠEK, Petr and colleagues. 2010. Tracheostomy - indications and technique. [online]. Available at: http://zdravi.e15.cz/clanek/priloha-lekarske-listy/tracheostomie-indikace-a-technika-provedeni-454039. [accessed 2012-12-14].
VOJTOVÁ, L. Help for patients with colostomy. Nurse, 2011, no. 51
ZACHOVÁ, V. Stoma. Prague: Grada. ISBN 978-80-247-3256-5
Other sources: https://otik.uk.zcu.cz/bitstream
personal consultations and cooperation with GIT Department of Liberec Hospital- MUDr. Lenka Nedbalová

1 Elišková, Maňka: 2006
2 Vojtová: 2011
3 Zachová: 2010
4 Zachová: 2010
5 Mariňáková: 2008
6 Mariňáková: 2008, Michálková: 2010
7 Tracheostomy – opening into the trachea, a procedure ensuring ventilation
8 Schwarz, Matoušek and colleagues: 2010
9 Novák, Zemanová: 1989, Marková: 2006
10 Novák, Zemanová: 1989, Zachová: 2010
11 René Descartes (René Descartes, 1592–1650), founder of modern methodology. In his concept of the human ego as MENS—mind, distinguished from subjectivity, with first meditations specifying this subjectivity, is what we apprehend first. Descartes’ concept of world is dualistic (in the sense of universe). It is based on two basic principles—thinking and matter. This dualism is not only ontological but also epistemological, meaning that methods of investigating body differ entirely from methods of investigating psyche—the soul. Because the methodology of embodiment is highly verifiable (controllable), it became the general methodological paradigm for all kinds of science. Husserl called this mode of thought “more geometrico.”
12 Patočka: 1999
13 Merleau-Ponty: 1998
14 Phantom pain after amputation is a typical sign of the breakdown of structural and non-structural body schema. A similar situation also occurs after orthopedic surgeries when metallic material such as a nail or screw is introduced into the patient’s body. Metallic material—a nail in the floor remains a nail; in a patient’s body it becomes part of structural and non-structural schema, and in the claim of embodiment it becomes part of the intentionality of that person.
15 Aretace (the ability to restore unity at every moment of human life, harmonizing basic ontological oppositions). The opposite of aretace is dysaretace, a broken ability to balance and harmonize; the result is non-power in the sense of inability or inability to realize one’s possibilities (understood in a phenomenological—Heideggerian—sense).