How to treat hypergranulation tissue around percutaneous endoscopic gastrostomy (PEG) tubes?

Treatment of Hypergranulation Tissue Around PEG Tubes

Hypergranulation tissue around PEG tubes should be treated with a combination of daily cleaning, topical corticosteroids, silver nitrate cauterization, or antimicrobial agents depending on severity, with topical corticosteroids being the preferred first-line treatment for most cases. 1

Understanding Hypergranulation Tissue

Hypergranulation (overgranulation) tissue is a common complication of PEG tubes characterized by:

• Vascular tissue that bleeds easily
• Tissue that extends above the level of surrounding skin
• Sometimes painful tissue around the tube site
• Potential to delay wound healing and increase infection risk

Common Causes of Hypergranulation

• Excess moisture around the PEG site
• Excessive friction or movement from a poorly secured tube
• Critical colonization or infection of the site
• Leakage of gastric contents
• Improper tension between internal and external bolsters

Treatment Algorithm for Hypergranulation Tissue

Step 1: Prevention and Basic Care

• Clean the affected skin at least once daily with antimicrobial cleanser
• Ensure proper tension between bolsters (avoid excessive pressure)
• Minimize tube movement
• Apply barrier film or cream to protect surrounding skin

Step 2: First-Line Treatment

• Topical corticosteroid cream or ointment (preferred first-line treatment)
  • Apply medium to high-potency corticosteroid for 7-10 days 1, 2
  • Use in combination with foam dressing to provide compression 1
  • Recent evidence shows faster healing with 1% hydrocortisone compared to silver nitrate 3

Step 3: Alternative or Additional Treatments

• Silver nitrate cauterization

  • Apply directly to hypergranulation tissue
  • Note: May be painful and can lead to scarring 4
  • Less effective than topical steroids according to recent research 3

• Antimicrobial options

  • Apply topical antimicrobial agent under fixation device
  • Use foam or silver dressing over affected area
  • Change only when significant exudate present (at least weekly)

• Combination therapy

  • Consider 50/50 mixture of triamcinolone and antibiotic ointment for resistant cases 4

Step 4: For Refractory Cases

• Surgical removal of hypergranulation tissue
• Argon plasma coagulation
• Consider changing to alternative brand or type of gastrostomy tube 1

Special Considerations

• Infection management: If signs of infection are present (erythema, purulent discharge, fever), obtain a swab for culture and treat with appropriate antimicrobials 1

• Leakage management: Address any gastric content leakage which can exacerbate hypergranulation:

  • Apply hydrocolloid wafer as keyhole dressing
  • Use foam dressings rather than gauze (foam lifts drainage away from skin) 1
  • Treat any fungal infections with topical antifungal agents

• Tube stabilization: Correct side torsion by stabilizing the tube using a clamping device or switching to a low-profile device 1

Monitoring and Follow-up

• Assess response to treatment within 2 weeks
• Most cases should show significant improvement within 4 weeks
• If no improvement after 4 weeks of appropriate therapy, consider alternative approaches or specialist referral

Treatment Efficacy

Recent research indicates that:

• Topical corticosteroids result in faster healing compared to silver nitrate (median reduction in wound size of 14-15 mm vs. 0-5 mm) 3
• Combination treatments with corticosteroids and antibiotics show resolution in approximately 95% of cases 4
• Average time to resolution with topical treatments is approximately 27.5 days 4

By following this structured approach to hypergranulation tissue management, PEG tube complications can be effectively managed, improving patient comfort and reducing the risk of further complications.