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Saturday, December 15, 2012

Granulation Tissue 101

Granulation tissue is the nemesis of tubies everywhere. Some are lucky enough to never experience it and others are not. Raya has been one of the unlucky ones so far. It can happen with ANY type of stoma, not just feeding tube stomas. In case you've never seen it, here's what it can look like:
It is usually somewhere between light pink and bright red, shiny, and has kind of a wet appearance. These are just 2 examples. It varies greatly from person to person. The first picture was when Raya was 8 or 9 months old and the second was this week.

Granulation tissue is a result of the body's natural wound healing process. This process includes 3 phases (4 if you include the initial hemostasis phase, i.e. stopping the bleeding): inflammatory, proliferation, and maturation. In the inflammatory phase, the body's immune system triggers the release of chemicals and specialized white blood cells that flood the area and destroy any invading bacteria as well as "digest" any dead cells. This is the stage where the wound is swollen, red, and can be hot to the touch. The proliferation phase is where granulation tissue comes in. Granulation tissue is made of mostly collagen fibers and newly formed capillaries that carry needed blood flow to the area in order to bring nutrients and oxygen that are essential to healing and forming new tissue in the area. In most cases, granulation tissue is a good thing. It is the body's way of generating new tissue to close a wound. The maturation phase completes the healing process as the collagen fibers mature and a fibrous scar forms to fully close the wound. Despite what my anatomy textbook says, granulation tissue is delicate and bleeds easily.

In the case of a stoma with a medical device in it, the proliferation phase sometimes continues rather than moving on to the maturation phase, resulting in an excessive amount of granulation tissue. And boy can it be excessive. This is Raya's granulation tissue at just about its worst, back when she had only had her G tube for a couple weeks and the tube was the wrong size:
(and this is where her scar tissue came from) This was really bad. Her GI doctor's eyes just about popped out of her head when she saw it. The day before I took this picture, it hadn't been NEAR that big. We had already done a couple of silver nitrate treatments (which I'll get to later) and it was almost gone. Then that morning, she had a really bad vomiting/retching episode and BAM, there's this enormous granulation tissue. Doesn't it just make you cringe and put your hand over your non-existent G tube?

SO what do we do about granulation tissue? Here are a few things. This is by NO means an exhaustive list, just some things we've either done or that have been recommended to us:

1. Minimize friction.
The biggest enemy to a stoma is friction. Friction disrupts the healing process or causes the body to go back into healing mode and the granulation tissue starts forming again. The first thing you need to do is make sure that the tube fits properly. If the stem length is too long (which was the case with Raya's Bard button in the above picture), the tube needs to be changed out with the correct size, or if the tube can't be changed due to the tract not being fully healed yet, it needs to have a spacer added or have extra gauze around it to keep it fitting snugly. Having said that, we did #3 and you can see how that turned out. A properly fitting tube is important.
Another important part of minimizing friction is to stabilize the tube during feeds. When you connect an extension tube, there will be added weight tugging on the stoma unless you secure the tube somehow. Not to mention that it increases the risk of the G tube getting pulled out. We tried many different taping methods including trying out MANY different kinds of medical tape and taping the tubes in different directions. We had been told that taping it up and then across would help minimize the tension on the stoma but that method did not work well for us. Our preferred method is to tape it to Raya's belly (usually on the right side but not always) with Hypafix tape like this:
This was when she had a GJ tube and had to be fed through the J port and drained from the G port continuously, hence the 2 extension tubes. Interestingly enough, within a couple of months of getting her GJ tube, her granulation tissue went away and never came back. The reason for that is because with 2 extension tubes on 24 hours a day, it couldn't twist so there was little to no friction. (GJ tubes aren't supposed to twist anyway.) It was a beautiful thing.

We also tape it like this sometimes:
Taping the extension tube up and across can help reduce the tension on the stoma. The difficult thing for us with this method is that Raya has a lot of sensory issues and for whatever reason, having the tape anywhere other than across her belly really bothers her so she ends up pulling it off. Honestly, taping it this direction doesn't seem to make a difference with her granulation tissue but it does help some people. The bottom line is just keeping the G tube stable and supporting the weight of the tubing by securing it to something during feeds so it's not tugging on the stoma.

I'm not suggesting leaving extension tubes connected all the time (unless you're doing continuous feeds) because that will wear out the port, but it's a good idea to secure the extension to something while the feed is going, whether it's taping it to the belly, making a tag with tape around the extension tube and pinning it to clothes, or taping it to the diaper. Anything you do to reduce the weight hanging on the stoma and reduce tugging and pulling from the extension tube on the G tube will help prevent granulation tissue.

2. Keep the stoma clean.
I think this is fairly obvious but keeping the stoma clean is very important. Most often, we just use warm water. Occasionally we use mild soap, but that's really all you need. I read somewhere that using hydrogen peroxide can actually make granulation tissue worse, and soaps can be irritating, so it's really best to stick to water and maybe a mild soap. If there is ANY leakage coming out from around the stoma, it is a good idea to keep either gauze or a cloth G tube pad around it to absorb the leakage so that it doesn't turn into dry crusties that have to be cleaned off later. Just be sure to change it frequently if there is leakage.

3. Protect the skin around the tube.
If you have leakage from around the tube, there are a couple of things that should be done. First, if the button is a balloon button, be sure that the balloon has an adequate amount of water in it. Manufacturers of G tube buttons give a suggested minimum to maximum range for the volume of a balloon. If you're experiencing leakage from around the tube and are closer to the minimum range, add more water to the balloon. If you're already at the maximum range, the tube may be the wrong size. With Raya's Bard button, we couldn't change the tube because it was her original tube from surgery so it had to stay in for 6-8 weeks. The hospital apparently only had 2 sizes and used the smaller size, but it was still too long so the best we could do to keep formula from pouring out of her stoma was to use 2 packets (4 layers) of gauze to keep tension on the inside of her stomach and prevent the leakage. Because it leaked so much, we changed the gauze several times a day so the skin really didn't have a chance to get irritated.
This week since her scar tissue removal has been a different story though. I did have to add water to the balloon because it was just below the minimum recommended amount. I'm not sure why it was low but we're watching it to make sure the balloon isn't leaking since it's only been in for a week and the surgeon was the one that put it in. Because her stoma is healing from the surgery, she's had a LOT of goopy green stuff coming out of it. (and yes, that's the technical term). The goopy green stuff is normal, but there's been a LOT of it. It irritates her skin and turns into the aforementioned dry crusties, even WITH gauze around the tube. In order to protect her skin, we've been using Calmoseptine ointment/cream. It's an over-the-counter product used to protect skin from any type of bodily fluid irritant. I found it in the adult diaper aisle, so yeah, it's good stuff. I got a great big tube for about $8 and it will last us forEEEEEEEEEVVVVVVEERRRRRRR since we use a tiny amount on the end of a Q tip a couple times a day. (Calmoseptine is also available in Australia, Canada, and the Philippines)
So in summary, if there's leakage, try to prevent the leakage. If you can't prevent the leakage, keep the area clean and use a barrier cream like Calmoseptine to protect the skin.
**Note: G tube manufacturers (at least MicKey and AMT Mini One) specifically say NOT to use petroleum-based products (aquaphor, petroleum jelly, etc.) on G tubes because petroleum can cause breakdown of the silicone. This was verified for me by the manufacturer of MicKey via email.**

4. Triamcinolone cream (aka Kenalog).
Kenalog cream is a corticosteroid used for conditions like psoriasis. Corticosteroids have anti-inflammatory and anti-itch properties, which is why Kenalog is helpful for treating granulation tissue. It is available by prescription only. I wish I could say we're using it and it's helping, but we have not been able to get a prescription for it yet. Hopefully on Tuesday when we see the surgeon. I've also been told that steroidal nasal sprays help with granulation tissue but that's not something I would try without running it by the surgeon first.

5. Mepilex Ag wound care dressing.

Mepilex Ag is an antimicrobial foam wound care dressing that absorbs wound exudate and releases silver into the wound. (It looks green in the picture but it's really gray.) It comes in 4x4 sheets so for a G tube stoma, you can get 9 squares out of 1 sheet.
We tried to use it when Raya had her Bard button but because of the profuse leakage of formula from her stoma, we couldn't because it would get completely saturated with formula within a few minutes. Another road block we ran into was that it's considered a wound care product and insurance didn't consider a new G tube stoma to be a wound. {REALLY???} So we got a few samples from the surgeon's office but didn't really use them. Thankfully, I didn't get rid of it because we've been using it this week to try and ward off the new granulation tissue she's getting. I'm not sure how much it's helping but we'll keep doing it. The nice thing about Mepilex is that it has a gentle adhesive on the back so it will adhere to dry skin but it won't stick to the granulation tissue.

6. Silver nitrate sticks.
Silver nitrate sticks are the big guns in treating granulation tissue. In my opinion, silver nitrate sticks should be the last resort for treating granulation tissue. Many doctors (including our surgeon) disagree with me on that and seem to use that as the first treatment option. If you have a choice, try everything else and it doesn't work, THEN try the silver nitrate sticks. Silver nitrate is a chemical compound (AgNO3, in case you were wondering) that is used to cauterize wounds. When you use silver nitrate sticks, you are chemically burning the tissue. I've been told by many people who have had silver nitrate treatments that it's very painful. I didn't realize this but you can actually buy it from various sources without a prescription to use as a treatment for canker sores. Sounds like self torture to me but to each his own. I would NOT recommend buying them to use on granulation tissue though. Treatment of granulation tissue with silver nitrate should be done by a physician unless otherwise directed. Raya's was treated by her surgeon, her GI, and then we did it a couple of times at home under the direction of her GI. It was not pleasant.
If you do use silver nitrate sticks, it's a good idea to use a thin layer of Aquaphor on the health tissue around the stoma to protect it. (again, avoid getting it on the G tube since it can damage the silicone and I've also heard it can trap bacteria in the area, which is not good either) Be forewarned, silver nitrate will turn the tissue a grayish-black. We had been told by one of her doctors that it wasn't necessary to put aquaphor on the healthy tissue so we didn't and she ended up with a black ring around her stoma for a while. It didn't hurt her healthy skin, just stained it. Even the tiny little hairs that we didn't know were there turned black.
**Update: Another note about silver nitrate. When we first used it after Raya's initial G tube placement surgery, we were instructed to apply it to the whole surface of the granulation tissue. This time around, we've been shown to only apply it to the very inner ring of the granulation tissue closest to the G tube. The reason for this is because that is where the new growth comes from. Using it this way turned out to be less painful for her and more effective than applying it to the whole surface.

7. Cloth G tube pads.

Photo courtesy of Sugary Monkey. :)
Many people swear by cloth G tube pads instead of gauze to help heal & prevent granulation tissue. I've heard a lot of people say that once they started using cloth G tube pads, their child's (or their own) granulation tissue went away and never came back. That has not been our experience but hundreds of other people LOVE them. I do too, they're WAY cuter than gauze & tape, we just don't really use them very often. :) There are a lot of small businesses who make and sell them on their own websites or on Etsy. Most of them are parents of tubies or former tubies, so they know what works and develop products based on experience. Here's a list of several of those businesses.

We've tried 3 or 4 different "brands" of cloth G tube pads. I like them, but ultimately my dislike of keeping track of tiny things in our mountains of laundry wins out over my like for them. I was using them regularly for a while but then Raya kept having blood come out of her stoma so I stopped. I didn't want to stain the G tube pads and it's easier for me to see what's coming out of her when I use plain white gauze. I also like being able to just throw away the yuckies.

7. Other...
There are other home remedies for irritated stomas & granulation tissue as well. For irritation from leakage around the stoma, you can use a Q tip to apply liquid antacid like Maalox or Mylanta. This will help neutralize the stomach acid so that it doesn't burn the skin. Tea tree oil (aka melaleuca) is another over-the-counter option. Tea tree oil is said to have anti-inflammatory, antibacterial, and anti-fungal properties, as well as analgesic (pain relief) properties. If you've never used it before, it wouldn't be a bad idea to test it on another area of skin to make sure there won't be any allergic reaction.


I had really hoped we wouldn't have problems with granulation tissue again after Raya's scar tissue removal but it's coming back. We knew it probably would but really hoped otherwise. Just so you can see what it looks like, here's the progression we've seen over the last 11 days with the top left being the day of the surgery and the bottom right being yesterday.
(obviously removing old nail polish is not very high on my priority list.) Her granulation tissue is not the bright red that we saw when she was 8 months old but it seems to bother her more now than it did then. She's been very defensive of anyone touching her tube and tells me fairly often that her tubie hurts. (and this is the kid with the ridiculously high pain tolerance who was swinging from the kitchen table a couple days after breaking both bones in her forearm)


Like I said, this is in no way an exhaustive list. I know there are other creams and dressings out there that can help granulation tissue, these are just the ones I'm familiar with. The biggest items on that list are minimizing friction and keeping the stoma clean. Stoma care and preventing/treating granulation tissue is another inexact science that involves trial and error to see what will work best for you. What works for one person may not work for another, so these are just a few suggestions.

5 comments:

  1. Thank you, Brandis, for the information. I had to smile about the one day none...and then poof! There it is! I live in that world.

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  2. This is incredibly helpful, thank you, thank you, thank you for taking the time to share this great information.

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  3. This is the only place on the internet with this kind of exhaustive information about granulation tissue when related to g-tubes. Thank you sooooo much! I hope Raya is well.

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  4. Wow what a great article to come across. Thank you for all your research and trial and error. I sure hope you lil girl is doing well :-) It helps so much to hear other parents go through he same issues i do. My son got his mickey in December and i cause him problems with infection and granulated tissue from the beginning, We switched to the mini one which seems to be a big help, it looks better but still hasn't stopped giving him problems. We are always battling it everyday. The one thing i found that helps most is the friction you talk about and keeping the mini tight to the stoma. That seams to do the trick in helping it heal till he gets active time to time while i feed him and it moves around with the extension and all our problems start again. Now its bleeding (AHH!! never ending!!) to all the moms out there caring for you special lil ones. BLESS ALL THE MOM'S YOUR BABIES!!! Its exhausting everyday but so worth every minute!! God gave us these kids because they were meant for special MOMS like us!!!

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  5. You might also try "Stomahesive" protective powder. It continues to work wonders with my son's granulation tissue.

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