Figure 5.34. Prolapsed ileostomy. (A) Supine film of the abdomen shows a bilobed soft tissue density overlying the lower abdomen and pelvis. Its high density represents the sharp boundary with the surrounding air and not increased density of the mass itself. (B) CT scan of the same patient demonstrates the two prolapsed loops of small bowel lying on the anterior abdominal wall. The extent of the prolapse is very unusual.

Figure 5.35. Parastomal hernia. Steep oblique film from a small-bowel series demonstrates multiple loops of small bowel coiled within the anterior abdominal wall at the site of an ileostomy.

Parastomal hernias may be detected on routine contrast studies (Fig. 5.35) or CT images. The key to the diagnosis on routine contrast studies is the use of a steep oblique or even lateral position to bring the stoma and prestomal loop into tangential view [108] (Fig. 5.36). In addition, the use of a cone stomal appliance (Fig. 5.37) makes performance of the exam easier and avoids the use of a balloon catheter that could cause damage to the prestomal loop or the stoma itself [108]. On CT imaging, the finding of loops of small bowel in the anterior abdominal wall, other than the prestomal loop itself, makes the diagnosis self-evident.

Kock introduced the continent ileostomy in 1969 [109]. He fashioned a low pressure, highly compliant reservoir to be used in postprocto-colectomy patients. By leaving the patient with a noneverted flat stoma and eliminating the need for a collection bag for waste products, the patient was afforded an improved body image and could pursue a more active lifestyle.

Figure 5.36. Parastomal hernia (and the value of a steep oblique film). (A) Frontal film from a small-bowel series shows multiple small-bowel loops in the right midabdomen without evidence of a hernia. They have lost their usual serpentine arrangement. (B) Spot film in a steep right posterior oblique position shows a knuckle of small bowel in the anterior abdominal wall, a parastomal hernia.

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