Gastrostomy (G, GJ, J) Complications — Granulation Tissue — Clinical Pathway: Inpatient

G, GJ, J Tube Complications Clinical Pathway — Inpatient

Granulation Tissue

Granulation tissue is beefy, pink or red connective tissue that forms around the healing enteral tube site. It is ‘proud flesh’ that can form inappropriately as a result of trauma to the stoma site (e.g., pulling or snagging of the tube, irritation) and:

  • Thrives in a moist environment
  • Tends to have a high bioburden (lots of microbes and germs), which causes continued overgrowth

The goals of treating granulation tissue include:

  1. Minimize trauma to site — because tissue is very vascular, it can bleed easily. Re-traumatizing may cause new hypergranulation tissue to form.
  2. Treat the growth and shrink the tissue — manage moisture, reduce bioburden, and stabilize the tube to prevent trauma. This healing process can take several weeks.
  3. Prevent worsening and progression of the underlying cause — e.g., moisture from irritant dermatitis, leaking, wound, tension on the tubing.

Granulation Tissue

  Recommended Approach Comments

1st line intervention

(initiated by Bedside RN or FLOC)
  1. Document the site with images in Epic Media tab.
  2. Secure/stabilize the enteral tube to relieve pulling and tension on the stoma:
    • Position the patient to relieve tension
    • Secure tube away from environmental hazards (e.g., bedrails, IV pole, wheelchair & stroller wheels, etc.) using a securement device/dressing that is appropriate for tube.
  • Stabilizing the tube with a securement device removes tension, pressure, and tightness that contributes to granulation tissue formation.
  1. Manage/reduce moisture to keep the site dry:
  • As granulation tissue tends to weep, the goal is to maintain a dry environment and minimize moisture.

2nd line interventions if above steps fail

(initiated by FLOC with/out managing service)
  • There are two second-line options:

OR
  • Silver dressings require an Epic order and supply chain product delivery.
  • Triamcinolone  0.1% ointment/cream as follows:
    1. Apply 3 times per day x 7 days
    2. Stop use for 7 days
    3. After 7 days, repeat application for 3 times per day for 7 days.

    •  
  • Triamcinolone ointment is a topical steroid cream that can thin the surrounding skin. If no improvement after this regimen, discontinue use and notify the appropriate service.

Mild - Moderate Granulation Tissue

Mild granulation example 1 Mild granulation example 2 Mild granulation example 3

Severe Granulation Tissue

Severe granulation

Differentiating Prolapse from Granulation Tissue

Prolapse can be difficult to identify and differentiate from hypergranulation tissue. Prolapsed gastric mucosa tends to have a beefy red color and velvety, smooth appearance. Granulation tissue tends to be pink or red in color, feels spongy or firm, and looks bumpy. If unsure about prolapse, notify the appropriate service. Silver nitrate is contraindicated for prolapse.

Granulation Tissue

Moderate granulation

Prolapse

Severe prolapse

Following Bedside Treatments

If the granulation tissue is not improving after a regimen of triamcinolone, consider silver nitrate.   To apply, notify the appropriate service. Only a trained provider may place silver nitrate.

If all interventions fail, consult General Surgery for potential stoma revision.