How should a slight leak of fluid around a gastrostomy tube (G‑tube) stoma be managed?

Management of Slight G-Tube Drainage

For slight peristomal leakage around a gastrostomy tube, immediately check and correct bolster tension to maintain 0.5–1 cm of free space between the external bolster and skin, apply zinc oxide barrier protection to all exposed skin, start a proton pump inhibitor to reduce gastric acid secretion, and use foam (not gauze) dressings to lift drainage away from the skin. 1, 2

Immediate Mechanical Assessment

The first priority is identifying and correcting mechanical causes, as excessive compression between internal and external fixation devices is the leading risk factor for G-tube leakage and tissue necrosis. 2

• Check bolster tension: Verify there is 0.5–1 cm of play between the external bolster and the skin surface; excessive compression causes tissue necrosis and progressive tract enlargement. 1, 2
• Assess tube mobility: The tube should advance inward at least 2 cm (ideally 5–10 cm) without resistance; any difficulty mobilizing the tube is an alarming sign of buried bumper syndrome requiring urgent endoscopic evaluation. 1, 2
• Verify balloon volume (if balloon-type device): Check that the balloon contains the manufacturer's specified volume, as deflation or incorrect filling allows tube migration and leakage. 1, 2
• Inspect for side torsion: Side torsion of the tube leads to ulceration and progressive tract enlargement; stabilize the tube with a clamping device or switch to a low-profile device if torsion is present. 1, 2

Skin Protection Protocol

Small peristomal drainage in the first week after placement can be normal, but any persistent leakage requires aggressive skin protection to prevent acid-induced breakdown. 1, 2

• Apply zinc oxide barrier: Use zinc oxide-containing barrier films, pastes, or creams to all exposed peristomal skin to prevent gastric acid from causing chemical burns. 1, 2
• Use foam dressings: Place foam dressings (not gauze) over the site; foam lifts drainage away from the skin and reduces maceration, whereas gauze traps fluid against the skin and worsens breakdown. 1, 2

Medical Management

• Start proton pump inhibitor therapy: Initiate a PPI to decrease gastric acid secretion and minimize both the volume and corrosiveness of leakage. 1, 2
• Treat fungal infection if present: Apply topical antifungal agents if there is evidence of fungal colonization, as chronic moisture creates a vicious cycle of infection and leakage. 1, 2
• Address gastroparesis: Consider prokinetic agents if gastroparesis is contributing to increased gastric residuals that overflow around the tube. 2
• Manage constipation: Treat constipation aggressively, as increased intra-abdominal pressure forces gastric contents around the tube. 1, 2

Infection Assessment and Treatment

Peristomal infection occurs in up to 30% of cases with leakage and causes local tissue breakdown. 2

• Inspect for infection: Look for erythema, warmth, purulent drainage, or tenderness at the stoma site. 1, 2
• Clean daily: Use an antimicrobial cleanser at least once daily to reduce bacterial load. 3
• Treat bacterial infection: If infection is present, obtain a culture and treat with oral broad-spectrum antibiotics for 5–7 days. 2

Management of Excessive Granulation Tissue

Excessive granulation tissue is a common problem that contributes to leakage through chronic moisture and friction. 1, 3

• First-line treatment: Apply topical corticosteroid (clobetasol 0.05% or triamcinolone 0.05%) twice daily for 7–10 days, covered with a foam dressing to provide compression; this resolves hypergranulation in approximately 95.7% of cases. 3
• Second-line treatment: If hypergranulation persists after the steroid course (approximately 4.3% of cases), apply silver nitrate cauterization directly to the tissue. 3
• Third-line options: For refractory cases, consider surgical excision or argon plasma coagulation. 3, 4

Critical Pitfalls to Avoid

• Do not upsize the tube: Replacing the tube with a larger-diameter tube is ineffective and typically worsens leakage by further enlarging the stoma tract. 1, 2
• Do not use hydrogen peroxide after the first week: It irritates the skin and contributes to stomal complications. 2, 3
• Do not ignore difficulty mobilizing the tube: This is an alarming signal for buried bumper syndrome requiring immediate endoscopic evaluation. 2
• Do not use gauze dressings: Gauze adheres to tissue, causes trauma on removal, and promotes maceration compared to foam dressings. 2, 3

Advanced Interventions for Refractory Leakage

If conservative measures fail after optimizing all mechanical factors, skin protection, and medical management:

• Temporary tube removal: Remove the tube for 24–48 hours to permit slight spontaneous closure of the tract, allowing the replacement tube to fit more closely. 1
• Argon plasma coagulation: Perform circumferential fulguration of the mucosa surrounding the tube with pulsed APC at 50 W and 1 L/min flow rate; this technique resolved persistent leakage in all four cases in a 2021 case series without complications. 4
• Convert to gastrojejunostomy: Consider converting the leaking gastrostomy to a gastrojejunostomy tube as an alternative treatment option. 2
• Place new gastrostomy at different site: If the original tract cannot be salvaged, place a new gastrostomy at a new location. 1, 2

Patient-Specific Risk Factors to Address

• Optimize glycemic control: Hyperglycemia impairs wound healing; elevated blood glucose must be controlled to promote tract repair. 2
• Address malnutrition: Poor nutritional status hinders wound healing and increases infection risk. 1, 2
• Review immunosuppression: Chronic corticosteroid or immunosuppressive therapy increases the risk of infection and leakage. 2