What to do for a blister or swelling around a percutaneous endoscopic gastrostomy (PEG) tube?

Management of Blister or Swelling Around PEG Tube

For blisters or swelling around a PEG tube, protect the skin with zinc oxide-based products, clean the area daily with antimicrobial cleanser, and check for proper tube positioning to prevent further complications. 1

Assessment and Initial Management

• Inspect the site for signs of infection (redness beyond 5mm, pain, exudate), leakage of gastric contents, or excessive granulation tissue 1
• Clean the affected area at least once daily using an antimicrobial cleanser to prevent infection and promote healing 2
• Apply a barrier film, paste or cream containing zinc oxide to protect the surrounding skin from gastric acid damage 1
• Use foam dressings rather than gauze to reduce local skin irritation, as foam lifts drainage away from the skin while gauze can contribute to skin maceration 1, 2

Management of Specific Complications

For Peristomal Leakage:

• Apply zinc oxide-based skin protectants to minimize skin breakdown due to leakage 1
• Consider starting proton pump inhibitors to decrease leakage by minimizing gastric acid secretion 1
• For fungal infections associated with leakage, apply topical antifungal agents 1
• Verify proper tension between the two bolsters, avoiding unnecessary tube movement or excessive pressure 1

For Excessive Granulation Tissue:

• Apply topical antimicrobial agents under the fixation device 2
• Consider foam or silver dressings over the affected area, changing only when significant exudate is present 2
• For persistent granulation tissue, cauterization with silver nitrate applied directly onto the tissue may be effective 1
• Alternative treatments include topical corticosteroid cream or ointment for 7-10 days combined with foam dressing to provide compression 1, 2

Tube Positioning and Maintenance

• Check that the external fixation plate is properly positioned with free movement of at least 5mm to prevent pressure-related lesions 1
• After initial healing (approximately one week), rotate the tube daily and move it inward at least once weekly (2-3cm) to prevent buried bumper syndrome 1
• Return the tube to its initial position with 0.5-1cm free distance between the skin and external bolster after mobilization 1
• For tubes with balloon retention devices, check the balloon volume content weekly to ensure it matches manufacturer's recommendations 1

When to Seek Advanced Care

• For persistent infection despite local care, obtain a wound swab for microbiological examination and consider antibiotic treatment 1
• If leakage is severe, consider temporarily delaying or stopping enteral nutrition, and implement gastric decompression 1
• For refractory cases of leakage, removing the tube for 24-48 hours may permit slight spontaneous closure of the tract 1
• If all measures fail to control leakage or infection, a new gastrostomy may need to be placed at a different location 1

Common Pitfalls to Avoid

• Avoid replacing the tube with a larger-diameter tube, as this can result in an enlarged stoma tract with more leakage 1, 2
• Do not use gauze directly on granulation tissue as it can adhere to the tissue and cause trauma upon removal 2
• If the device is a gastrojejunostomy or has a jejunal extension, do not rotate it (only push in and out weekly) 1
• Avoid excessive manipulation of granulation tissue, which can cause bleeding and pain 2, 3