How I finally succeeded in beating Hypergranulation!

The surgically created tunnel that forms around a gastrostomy tube where it connects to  a port on the outside of the body  is called a stoma. And, that stoma, for many people, can have long term problems with the formation of granulation tissue overgrowth. The old terminology for this is proud flesh.

Even though we may not consider a feeding tube that is surgically placed to be a wound, our body does.  It cannot differentiate between an accidental wound, and one that has been intentionally created.  And when that wound healing is interrupted for various reasons, a tube feeder can find themselves dealing with an ongoing, and seemingly endless headache of trying to fix the problem. And usually this means  without much help from medical providers.

If you have swollen, red, lumpy, moist tissue or flesh around the stoma site, then it is most likely  hypergranulation tissue. This tissue can a exude yellow, sticky pus. It may be painful, bleed easy, and prevent your stoma from healing the way it should.  Hypergranulation can occur for no apparent reason (friction, moisture or irritation may be contributing factors), especially during the first three months after the tube has been placed.

There is a great difference between chronic wound healing and acute wound healing, and they are not interchangeable.  For some, our body identifies the stoma to be a chronic wound, and complete healing does not take place, sometimes indefinitely.

The healing process associated with an acute wound is a dynamic one which can be divided into three phases (Dealey 2007): • Inflammation • Proliferation • Maturation

If certain triggers take place, and the stoma  is subjected to prolonged inflammation caused by infection or foreign body irritant (yes, that foreign body is the feeding tube)  what happens is the  stoma (wound) can get  ‘stuck’  in the healing cycle, the wound dynamics will change and the wound will not continue to fully heal.

The following are excerpts  from a UK publication  Wound Care Today.  I know its kind of dry and uses a lot of medical terminology, and you may be tempted to not bother reading it all ; but, make the effort, as it is a very good explanation of the whats and whys of granulation tissue formation.

Granulation tissue is an intermediary replacement for normal dermis, which matures into a scar during the re-modelling phase of wound healing (Johnson, 2007).  Granulation incorporates a dense network of blood vessels – newly growing capillaries (angiogenesis) – with an irregular upper layer created by the capillaries looping together on the wound surface. This gives granulation the appearance of red lumps (or granules) within the normal paler pink matrix, although despite this appearance, granulation does not bleed easily (Dowsett, 2002). Granulation tissue demonstrates an elevated cellular density incorporating fibroblasts and macrophages, as well as randomly organised collagen fibres (Ovington and Schultz, 2004).

The presence of granulation tissue in the wound is a sign that healing is taking place and this new tissue will protect the wound from bacterial colonisation since it is resistant to infection (Dealey, 1999; Dunsford, 1999; Collins et al, 2002). Many factors can delay wound healing (Hampton and Collins, 2003) and a lack, or an over-proliferation, of granulation tissue may delay healing and lead to a chronic wound… When granulation ‘over grows’ beyond the surface of the wound, this is known as overgranulation, also referred to as hypergranulation, exuberant granulation, hyperplasia of granulation, hypertrophic granulation or ‘proud’ flesh. It is usually present in wounds healing by secondary intention and is clinically recognised by a friable red, often shiny and soft appearance, which is raised above the level of the surrounding skin (Figure 3) (Johnson, 2007). The tissue can be healthy (Figure 4) or unhealthy (Figure 5) (Harris and Rolstad, 1994)…. However, whether or not the overgranulation is regarded as healthy or unhealthy, the wound generally will not heal when the tissue is ‘proud’ of the wound because epithelial tissue will be impeded from migrating across the wound’s surface and contraction halted at the edge of the swelling…

The exact aetiology of overgranulation is unknown. The literature often links infection with overgranulation, but it is not clear which occurs first.

Vuolo (2010) suggests there are three types of overgranulation (see Table 1):

  • Type 1: inflammatory with excessive exudate due to continued minor trauma or friction from mobility
  • Type 2: occluded wound environment (possibly due to infection or chronic colonisation) (Bannerjee, 1999; Vandeputte and Hoekstra, 2006)
  • Type 3: cellular imbalance – an imbalance between collagen synthesis and degradation due to the patient’s pathology.

Although I can speak only from  my own experience, and from what I have read, I believe that for the most part, those of us with feeding tubes who develop a problem with granulation tissue, have this problem due to Type 1 (above).  I  think it can also be for more than one reason, so determining  the root of the problem is not always clear-cut.  That may also be why some people will swear by one topical treatment, while another won’t find it effective at all.

It doesn’t have to be anything overly severe to keep that granulation formation process perpetuating.    For example, it doesn’t have to be a major  infection,  just a little bit of a fungal infection due to the moist environment; or frequent–even if slight– movement of the feeding tube.   Maybe  skin around the tube gets stretched during daily activities, or too much pressure is placed on those newly formed  blood vessels due to lifting something heavy, (grocery bags)  or moving something heavy around(vacuum cleaner) .

After dealing with granulation tissue for many years, and finally getting rid of it for a period of months, having it recur, and then getting it to go again, I’ve finally figured out what works for me.

Before I go on, I should  interject that I have a tape adhesive allergy, and this has further complicated managing my tube.

A few months ago I discovered a tape that uses zinc oxide instead of the usual acrylic  type of adhesives, and I have zero reaction to it!  Its a fairly ugly bright pinkish orangy color (oh well)  and the name of it is Hy Tape.

Friction is the ENEMY!  Keep the peg tube completely immobile except for daily turning, and when cleaning skin under the button or flange.

No matter what topical product you are applying, until the cause is addressed and corrected, that tissue will come back.

For example, silver nitrate sticks work the very fastest. It will make that tissue  shrivel almost instantaneously. This is because it is very caustic and it chemically cauterizes what it touches.  But, unless the reason for the hypergranulation formation has been address,  it will come right back with a vengeance.

Astringents are mild caustics, and they work slower, but with the same results. Alum is an example of a mild caustic (astringent). It is very gritty in the pickling spice form we find on our grocer’s shelf.  Granulotion contains a micronized version of alum. With repeated application, this has the same effect as the silver nitrate sticks, just at a slower pace.

Topical steroid application will  get rid of it fairly fast, but only while you’re using it.    Steroids work by reducing and eliminating inflammation, regardless of what is causing the inflammation. It is a painless way to treat granuloma, and can be safely used on a regular daily basis for several weeks, before one should taper off use.

Steroids have several strength classifications, hydrocortisone is the mildest, and will not be effective.  A  class 4, mid strength, such as Kenalog (generic is Triamcinolone acetonide ) is what is needed.  And, the 1% works a lot faster than the .025%

Using a cream such as triamcinolone for a few weeks will make the problem go away, or mostly go away.  But, it, like the other topicals listed above, they  do not fix what is causing the problem.   Before you taper off using it, you absolutely need to try to figure out what is causing this cycle of overgranulation tissue to be taking place, and take steps to fix that. Because, when hypergranulation occurs, it is a way of the body saying, hey, I’m no longer an acute wound in the normal healing process, the body has decided it has a chronic wound, and the healing process has been interrupted indefinitely.

Now, if the overgranulation has sprung up in response to inflammation from an infection (either bacterial or fungal), and that infection is completely cleared up by treatment with either an antibiotic or antifungal, then, yes, you might be rid of it for good.  Odds are, though, that it is a combination of factors causing it, and so you need to examine all possibilities for what is the main perpetrator,

In retrospect, the issue is not so much how to get rid of already formed granulation, the issue is  finding the root cause of its formation and breaking  the cycle.

 

When my tube was first placed, I had the long dangler tube. I was statistically one of  the few that developed an infection at the site, and was on antibiotics  for about six weeks. Unfortunately, fierce problems with granulation tissue sprung up by the third week following its placement.  As I couldn’t tape it to keep the weight from tube from pulling on the stoma, and  minimize friction in general, my doctor opted to go ahead and place a low profile button tube sooner than originally planned.  He had always wanted me to graduate to the low profile style of tube, but, ideally he wanted to wait longer for the tract to heal

Switching to a button helped quite a bit, but did not rid me of the plague of hypergranulation tissue.   Years passed, and throughout that time, I tried to find the solution, but there was never any long term relief,

 

 

So, why are things different now after all of these years?

For a period  of a few months I had a different button type peg tube other  than the more well known brands (i.e. the Mic-key and AMT Mini one)   The Corflo  cuBBy is different in that it has a unique flower petal design, which means it sits up a bit from the skin surface on little feet –the “flower petals”.   The feet make the button very stable, it doesn’t move nearly as much as a Mic-key or Mini one.  (See image below)  It was during this time, while I had the  cuBBY that I finally was rid of any sign of granulation tissue.   And, allowing airflow to my skin, as it is just  tiny bit elevated, put the kibosh  on fungal infection that tended to form on my skin surrounding my stoma in the past.

Image result for image of corflo cubby

Corflo cuBBy low profile

Corflo cuBBy low profile

 

The photo directly above is a picture I took after I’d had it for a while, and was still in the process of healing.   The only drawback that I found to using this type of feeding tube, is that because of those awesome feet, it is a bit harder to get under it to clean around the stoma.

After  three or four weeks, I began to have less “play” in the button and the perimeter of stoma at skin surface were “firmer”.

About the same time as I got the cuBBy I also started using a product called Wonder DT Lotion.  Its an underground cult type favorite for those with ALS, and a helpful member of an online forum told me about it.  This “lotion” is very thin, about the consistency of milk, and because it is so runny, it can go down into the stoma a  bit, whereas all of the other products I’d used  are thicker, and tend to stay mostly on the surface.   It also does not burn at all, its not caustic, and so I didn’t have to protect the rest of my skin from it when applying it.  I use it faithfully twice a day, every day.

And, although I believe it helps in maintaining a healthy stoma by its antimicrobial and antiinflammatory properties, for me, it was the friction factor that was the main culprit in triggering the granulation tissue formation cycle. The role Wonder DT  played was creating  an environment that did not encourage infection and inflammation.

Once I was finally rid of the granulation tissue,  things were going swimmingly until the anti-reflux valve on my cuBBy broke, and my doctor could  not get me that same model to replace it with, as the hospital he uses contracts with the other manufacturers.

My doctor was involved in changing my   tube out because I had an additional problem  unrelated to  the non functioning anti-reflux valve.  I’d previously discovered  that I could not remove my peg tube,  and because I couldn’t get it out, (never a problem before) my doctor and I wanted it to be changed in a hospital setting in case radiology needed to be involved.

It turned out that adhesions (scar tissue) had grown onto the tube, and my doctor was able to remove my old tube with a good bit of effort – but no endoscopy involved, thankfully.  And then  I was back to having a Mic-key instead of the cuBBy.   I should note that once he got the old tube out, we were both looking down into my stoma admiring it.  It was so pale and healthy, only a couple of tiny – smaller than a pin point – dots of red inside it.  No true granulation to be seen at all.

The very fact that it was scar tissue that was holding the old peg tube too tightly for me to remove it, exemplifies  how I went from a chronic wound, stuck in a non healing limbo, to a healed wound!  A scar is the indication that a wound has healed.

It didn’t happen right away, but gradually, within two months after replacing the cuBBy with the Mic-key, the granulation tissue was forming once again.

As I was still using the Wonder DT Lotion, the only thing that had changed was the type of button device.  As the big difference in buttons was the stability factor, and I was pretty much stuck with the Mic-key at that point, I was determined to find a way to stabilize it.

That was when I stumbled across the HY tape.  Happily my skin did not react to the HY tape.

Image result for image of hy tape

In a future post I will talk about how I figured out a way to keep my Mic-key friction free by  using a modification to the pads I sew, and just a smidgen of Hy tape,

What matters for the purposes of this post, is once I found a way to keep that peg tube from moving, the granulation tissue once again abated.

 

Keep  the stoma clean, but don’t use harsh cleansers or topicals on it. 

As irritation is definitely a factor in causing granulation tissue to hang around, don’t irritate it!  Don’t use peroxide or alcohol.  Don’t use  anything other than plain water or a mild soap when cleaning it daily.

Remove the crusties, they will cause irritation. Just think if you had a cold, and you left dried goop on your nostrils, do you you think your nostrils wouldn’t get irritated after a while?  Its the same principle.

The bottom line is keep the area clean as possible.  Just do it gently.

 

Keep it dry

Stomas can easily develop fungal infections as the area tends to stay moist due to secretions.

I personally use cloth pads.  I use them for several reasons, first because until very recently I knew I couldn’t tape a gauze sponge into place as I couldn’t use tape.  But, as importantly as that–or even more so, really– is I don’t want to “look” sick.  I don’t need a daily reminder that something is wrong with me by seeing a bandage there.

A pretty colorful tube pad looks a heck of a lot less “patient like” . They can be washed and reused over and over, they add to stability, and they allow the skin to breathe  a bit.   As I’ve always been a matching bra and panty sets kind of gal, I’ve gone so far as to try to at least color coordinate my tube pad to the rest of my underthings.  Why not doll her up a little bit?  She does a lot for me, as in allowing me to get needed nourishment!

You can purchase peg tube pads online at a vast number of eBay  and Etsy shops.  I sew my own, and will post  directions here on this blog probably in September. I’ve come up with a few variations that  address issues concerning keeping the peg tube from moving, as well as modifications to help with snapping and unsnapping the pad, when a lack of finger strength is a factor.

Below is a photo of the tube pad I have on as I write this. It has a tiny strap that snaps over the balloon port of my peg tube.  On the underside of this I have a short strip of Hy tape, and on top of the Hy tape, sandwiched between it, and one of the plastic snaps of the tube pad, is half of a dot (Dapper Dots double sided fabric tape, image is below).  This combination of  fastening  the peg tube to the pad, and then anchoring the tube pad with tape to my abdomen, keeps my peg from moving during the day, and that stabilization  is what I need to keep friction in my stoma to a minimum.  If you don’t have a tape allergy, the layer of Hy tape would be unnecessary, as Dapper Dots are intended to be stuck directly onto the skin.

 

casual fabric, everyday style peg tube pad . The strap that snaps over balloon port works in conjunction with double sided tape on underside of pad to immobilize peg tube, reducing friction to stoma

Image result for image of dapper dots

 

 

 

 

 

I hope this  post was  of  interest to you.  Please let me know if there is something you would be interested in me posting about.

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