How is inflammatory granulation tissue managed?

Management of Inflammatory Granulation Tissue

Inflammatory granulation tissue should be treated with a combination of daily cleaning, topical treatments, and in some cases, cauterization or surgical intervention, depending on severity and location.

Understanding Inflammatory Granulation Tissue

Inflammatory granulation tissue is a common complication that can develop around wounds, particularly around percutaneous enteral gastrostomy (PEG) tubes and other medical devices. It is characterized by:

• Vascular, friable tissue that bleeds easily and may be painful 1
• Excessive formation of new blood vessels and inflammatory cells 2
• Potential for impeding normal wound healing if not properly managed 2

Causes of Excessive Granulation Tissue

Several factors contribute to the development of inflammatory granulation tissue:

• Excess moisture around the wound site 1
• Excessive friction or movement from poorly secured tubes or devices 1
• Critical colonization, infection, or leakage around the site 1
• Poorly regulated inflammatory response during wound healing 2
• Side torsion of tubes resulting in enlarged stoma tracts 1

Management Approach

Step 1: Daily Cleaning and Skin Protection

• Clean the affected area at least once daily using an antimicrobial cleanser 1
• Apply a barrier film or cream to protect surrounding skin, especially if the granulation tissue is exuding 1
• For exuding wounds, consider foam dressings rather than gauze to reduce skin maceration (foam lifts drainage away from skin) 1

Step 2: Topical Treatments

• Apply a topical antimicrobial agent under any fixation device 1
• Consider a foam or silver dressing over the affected area, changing only when significant exudate is present (at least weekly) 1
• For fungal infections associated with granulation tissue, apply topical antifungal agents 1
• Consider topical corticosteroid cream or ointment for 7-10 days in combination with a foam dressing to provide compression 1

Step 3: Cauterization for Persistent Cases

• Apply silver nitrate directly onto the overgranulation tissue for chemical cauterization 1
• This approach is particularly effective for small areas of excessive granulation 1

Step 4: Advanced Interventions for Refractory Cases

• For persistent granulation tissue around tubes, consider stabilizing the tube using a clamping device or switching to a low-profile device 1
• In cases of tube-related granulation tissue, ensure proper balloon size and tube length are being used 1
• For severe cases, consider surgical removal of granulation tissue 1
• Argon plasma coagulation has been described as an effective treatment in literature 1
• For extensive wounds with granulation tissue, Negative Pressure Wound Therapy (NPWT) may be beneficial to promote healthy granulation and wound healing 1

Special Considerations for Different Wound Types

For PEG/Gastrostomy Sites

• Verify proper tension between internal and external bolsters while avoiding unnecessary tube movement 1
• Check balloon volume content weekly if a balloon retaining device is present 1
• In refractory cases, consider removing the tube for 24-48 hours to allow slight spontaneous closure of the tract 1
• If all measures fail, placement of a new gastrostomy at a different location may be necessary 1

For Open Abdominal Wounds

• For grade 4 open abdominal wounds with granulation tissue, NPWT can be used to encourage granulation tissue formation to support split thickness skin grafting 1
• Use a wound contact layer (e.g., non-adherent silicon layer) between NPWT wound filler and the wound bed to prevent damage to granulation tissue during dressing changes 1

Common Pitfalls to Avoid

• Avoid excessive manipulation of granulation tissue, which can cause bleeding and pain 1
• Do not use gauze dressings directly on granulation tissue as they can adhere to the tissue and cause trauma upon removal 1
• Replacing tubes with larger-diameter tubes is generally ineffective and can result in an enlarged stoma tract with more leakage 1
• Minimize dressing changes to prevent disruption of the healing process, especially with NPWT 1
• Do not ignore signs of infection, which may require systemic antibiotics in addition to topical management 1

By following this systematic approach to managing inflammatory granulation tissue, clinicians can effectively treat this common complication and promote proper wound healing while minimizing patient discomfort and preventing further complications.