DESPITE METICULOUS CARE, a gastrostomy tube (G tube) used to deliver enteral feeding and medication can trigger hypergranulation tissue growth at the insertion site. Apparently the product of inflamed epithelial tissue, hypergranulation may be the body's reaction to the G tube, a foreign body.
Red, moist, and fragile, hypergranulation tissue bleeds easily and may be painful. Besides increasing the patient's risk of infection, the tissue inhibits the migration of epithelial cells and normal wound healing. The clear or yellow drainage produced by hypergranulation tissue also complicates wound healing.
Although the exact etiology isn't known, these factors may encourage formation of hypergranulation tissue:
- moisture from drainage and bleeding, which increases the risk of infection and peristomal skin breakdown
- friction from mobility if the tube isn't anchored adequately. Check for correct placement by gently pulling the tube until you feel resistance. The tube bumper should be flush against the inner stomach wall. Secure it according to facility protocol. Many commercial anchoring devices are available.
- ill-fitting low-profile (also called skin-level) gastrostomy device (balloon or button type). The outer ring or flap should be about 1/8 inch from the skin. Assess the length of the device frequently—especially if the patient is a child, who may be growing rapidly. If necessary, place a slit 2x2-cm gauze pad between the outer flaps of the device and the abdomen for a snug fit.
When assessing a patient with a G tube, look for and ask about factors that might predispose him to hypergranulation. Also assess and document the appearance of peristomal skin.
Treating the problem
Traditionally hypergranulation tissue is treated by chemical cautery with silver nitrate sticks. You can apply silver nitrate with a cotton swab once or twice a day. The tissue will turn gray and slough off. This treatment can be painful. As a less painful alternative (especially for children), some clinicians apply 0.5% triamcinolone cream, a steroid, once or twice a day until the tissue resolves. However, this isn't a labeled indication for triamcinolone cream, and more research is needed to establish its safety and efficacy.
Another option is to place polyurethane foam over the granulation tissue to control moisture, collect drainage, and protect surrounding skin. (Follow the manufacturer's directions for securing the foam.) Tailor your treatment to your patient. Resolution time varies depending on the treatment used, the patient's condition, the amount of hypergranulation tissue, and any complications.
Dealing with drainage
Drainage from hypergranulation tissue can cause peristomal skin maceration and irritation. To protect surrounding skin, apply a skin barrier such as petroleum jelly, a skin sealant, or a protective barrier product. If skin breakdown or irritation has already occurred but you find no signs or symptoms of infection, apply a skin barrier such as zinc oxide cream or a protective barrier product. You needn't remove all the cream with every application. Just gently clean the site with water, pat dry, and apply more cream. Too-aggressive cleaning may disrupt healing.
An alternative is to place a pectin-based wafer on the peristomal skin to help healing and serve as a skin barrier. Cut it like a tracheostomy dressing, with an opening to fit around the tube or the device's shaft.
If an infection develops, notify the patient's health care provider and obtain an order for an antibiotic or antifungal cream, as indicated.
Teach your patient and his caregivers about hypergranulation tissue and tell them whom to contact if this tissue develops. Early intervention can reduce discomfort and improve the patient's life with the G tube.
Now retired, Suzanne Borkowski for many years was a wound/ostomy nurse practitioner and pediatric nurse practitioner in the department of pediatric surgery at Women and Children's Hospital of Buffalo (N.Y.).
Borkowski S. Similar gastrostomy peristomal skin irritations in three pediatric patients. Journal of Wound Ostomy and Continence Nursing
. 31(4):201–206, July/August 2004.
Crawley-Coha T. A pediatric guide for the management of gastrostomy tubes based on 14 years of experience. Journal of Wound Ostomy and Continence Nursing
. 31(4):193–200, July/August 2004.
Rollins H. Hypergranulation tissue at gastrostomy sites. Journal of Wound Care
. 9(3):127–129, March 2000.