Why Do I Have Pain Around My Colostomy or Ileostomy Site?
We have recently had a patient who had 5 years of pain in a surgical scar on his abdomen. He has suffered a large bowel perforation, which means that he had a hole that had developed in his colon or large intestine, most likely from diverticulitis. As you might imagine he became very ill and had to have emergency surgery. In order to repair this, the patient had to have a colostomy. This is a procedure where the large bowel is divided and instead of emptying into the rectum, it is now brought to the abdominal wall. While this is not a pleasant situation for any patient, it is often a life-saving procedure. The goal is to allow the inflammation to calm down in the abdomen while venting the large bowel and its contents through the abdominal wall into a bag. It takes a lot of courage to have a colostomy and as you can imagine, it really changes your lifestyle in almost every conceivable way. Very little is the same. The goal is to reverse the colostomy once the initial wounds have healed and the patient’s health has improved. Unfortunately, some patients will not have the opportunity to reverse this.
Fortunately, this particular patient was able to eventually have this reversed and his large bowel was put back together again and he was able to have normal bowel movements again. A relief for sure! But there was still one problem. Very soon after the operation he was having severe pain in the abdominal wall where the colostomy used to be. The postoperative pain just never went away. A few weeks turned, turned to months, then years.
He was evaluated several times and it turned out that he had developed a hernia, meaning that there was a weakening in the abdominal wall through which the intestines were bulging though, but the skin was totally healed. But his hernia did not hurt. He could put his finger on the pain, but the finger was not on the hernia.
The hernia had to be fixed to prevent further complications, so he went forward with the repair hoping to get relief from the pain. Unfortunately, he did not get any relief of the pain, though much to the credit of his surgeons, his abdominal wall was repaired nicely. No more bulge and the intestines were in the right place – inside.
But he still had severe life-limiting pain in the abdominal wall directly next to his previous colostomy incision. The patient could still put his finger right on the pain, and then when the pain started it radiated toward the lateral chest wall around the ribs. Every time he sat up, twisted, turned, sat up, coughed, sneezed, or laughed he could feel a sharp stabbing pain in the abdominal wall.
He saw Dr. Harrison Linder at Mercy Hospital in Baltimore 4 years after the pain began. Dr. Linder suspected that the intercostal nerve was the problem. These nerves come from the spine, along the ribs, and then into the abdominal wall. He gave him a diagnostic and therapeutic injection called a TAP block. This first block gave the patient months of relief, and for the first time in years, the patient did not have excruciating levels of pain. But his pain returned after several months and repeated blocks while giving him relief only worked for short periods of time.
Nerve Entrapment Can Cause Persistent Abdominal Pain
We were fortunate to see the patient for consultation and suspected that Dr. Linder was correct in that somehow an intercostal nerve that travels through the chest wall into the abdominal wall somehow had gotten caught in the location where the patient’s colostomy was located. Somehow when the bowel was put back together and the abdominal wall was repaired these nerves had been caught in a stitch or in scar tissue.
We provided more support for this by asking the patient to point to his pain in the abdominal wall and then we injected local anesthetic into the location of the intercostal nerves which would have correlated with this area of the body. His pain completely resolved while the medication was present. Therefore we elected to go to the operating room to look for these small nerves. They are only 1-2 mm in size and are typically very difficult to see especially when operating to repair the bowel and close the wound so a hernia will be unlikely. Surgeon’s like a nice snug repair with good tissue to close these wounds.
In the operating room, we did find two nerves that were stuck in his scar tissue, and one even had a stitch through it. It was the end of a 5-year mystery as to why he had a constant companion of pain. We were excited to find the “smoking gun.” We were able to remove the nerve and bury this small sensory nerve far from the surgical site into a soft protective muscle to try to prevent this from happening again and to try to prevent another painful neuroma from forming.
It was a successful operation and a successful outcome! The patient reported 95-98% relief of his pain that has been sustained now for months since his surgery. He was able to get off all narcotics, neuropathic medications, and may take only an over-the-counter medication from time to time. He was able to return to his prior activities! Needless to say, we celebrated with him!!!!
When to Consult With a Peripheral Nerve Surgeon for Colostomy Scar Pain
This made me wonder. There are literally hundreds of thousands of patients who have colostomies and colostomy reversals or ileostomies in the US every year. This patient CAN NOT be the only one out there who has severe debilitating pain around a previous ostomy site. These intercostal nerves are tiny but can cause a great deal of pain. Surgeons are not really trained to look for these when creating an ostomy or taking one down to repair an ostomy site. There have got to be other people out there who have had the unfortunate luck of having “drawn the short straw” and have gotten these nerves caught in a suture while the surgeon is busy trying to repair the abdominal wall so a hernia does not develop in the future. This article is written for you!
If you or someone you know has had a colostomy or an ileostomy (where they bring the small bowel up to the abdominal wall) and you are having severe, disabling sharp stabbing, electrical pain in the abdominal wall near your scar, and that pain radiates a bit around to the side.
Well, you just might have an entrapment of the intercostal nerve. The next steps are to contact your doctor, make sure there is not a hernia, then ask them if a “nerve block” would be appropriate. You can show off by asking them about the anterior cutaneous branches of the intercostal nerves that travel through the muscle and then into the skin through the rectus abdominis muscle; this is the same muscle through which the colostomy or ileostomy has been pulled through. Then if the nerve block works well for a few hours, ask to see a peripheral nerve surgeon.
We would be delighted to talk with you about this situation. We might be able to help you as well!