fluoroscopic guidance.
Peristomal Skin Irritation
Patients can present with G‐tube erythema for a variety of reasons. While the presence of skin irritation can be highly distressing to patients and caregivers, the cause is commonly nonurgent. However, it is vital that providers have a healthy differential in order to distinguish severe causes of peristomal irritation from those that are less severe.
Peristomal Leakage
Peristomal leakage of gastric contents is seen with most G‐tubes. Diabetes, malnutrition, and poor wound healing can increase the likelihood and amount of leakage secondary to poor approximation of skin tissue around the tubing. In addition, a tightly secured retention device, noted by dimpling of the skin, can cause an inflammatory reaction and lead to increased leakage of gastric contents.
Skin irritation from peristomal leakage can be distinguished from infection by the color, which is a faint pink instead of the deep red color of cellulitis (Figure 1.3a). Likewise, the skin is not tender. Finally, crusting around the tube site, that is, dried formula and gastric juices, should easily wipe away.
Treatment options for peristomal leakage include skin barrier creams such as zinc oxide and antacid treatment to decrease the acidity of the gastric contents. If the stoma appears too large for the tubing, do not increase the size of the tube. A larger stoma site is not because the patient grew or gained weight. The stoma size increases secondary to repetitive trauma from the tube moving within the stoma. Increasing the tube size will only stretch the stoma further and lead to greater leakage of gastric contents. Do not make this common mistake. Instead, remove the tube and allow the stoma to shrink in size over the next several hours. A stoma can close within as little as 24 hours, so a smaller catheter should be left in place to maintain patency of the stoma. Once the stoma has decreased to the appropriate size, place the original sized G‐tube into the site.
Stomal Cellulitis
Stomal cellulitis is distinguished from skin irritation by the deeper red color and spreading erythema around a G‐tube site with significant pain to touch (Figure 1.3b). Patients with poor wound healing and an immunocompromised state are at increased risk for cellulitis. Pathogens are typically skin flora including beta‐hemolytic streptococci and Staphylococcus aureus. In a well‐appearing child with otherwise no systemic symptoms, a first‐generation cephalosporin is adequate to treat streptococcal infection. If a patient is a known methicillin‐resistant S. aureus carrier or appears ill, coverage should include agents that treat methicillin‐resistant Staphylococcus aureus (MRSA) based on local antibiograms. The tube does not need to be removed in the setting of stomal cellulitis. If there is fluctuance around the tube, an ultrasound should be obtained to evaluate for a peristomal abscess. Peristomal abscesses will require bedside incision and drainage and broad‐spectrum antibiotic coverage.
Figure 1.3 (a) Peristomal leakage notable for dried crusted skin without surrounding erythema. (b) Peristomal cellulitis distinguished from simple leakage by the deeper erythematous skin extending from the G‐tube site. (c) Peristomal candidiasis distinguished from cellulitis by its satellite lesions.
Stomal Candidiasis
Stomal candidiasis is much less common than bacterial infections of the stoma. Patients with candidiasis should be well appearing and have typical satellite lesions around the stomal site (Figure 1.3c). Similar to other forms of candidiasis, treatment with topical antifungal agents alone (nystatin or clotrimazole) is sufficient.
Necrotizing Fasciitis
Necrotizing fasciitis of the stoma is an exceedingly rare but life‐threatening complication. The patient will have erythematous, edematous, and tender skin with bullae. The lesion will rapidly expand, and the patient will look toxic. Similar to all infections, those patients with poor wound healing, diabetes, and malnutrition are at greatest risk. Necrotizing fasciitis is a surgical emergency that requires immediate surgical evaluation, wound debridement, and intravenous antibiotic treatment.
Stomal Bleeding
Bleeding at the stomal site is one of three things: hypergranulation tissue, mucosal irritation with or without prolapse, and upper GI bleeding. Distinguishing between the three is important because, while, to the patient they may all be an emergency, the severity and treatment are dramatically different.
A granuloma is a well‐circumscribed, pearly piece of tissue adherent to the stoma (Figure 1.4a). It presents as chronic, low‐grade bleeding. Its cause is unknown, but it is thought to arise from repetitive trauma from the G‐tube rubbing against the stoma. Hypergranulation tissue is of low risk but causes significant distress among patients and caregivers. Treatment is largely topical, including 0.1% triamcinolone cream, commercially available granuloma‐reducing agents, and salt packing. These agents are not without risk; specifically, triamcinolone can cause skin thinning, systemic absorption, and may precipitate a fungal infection. Silver nitrate application, kenalog injections, electrocautery, and G‐tube site revision are used in more persistent cases.
Another cause of chronic mild stomal bleeding is mucosal irritation. This too is caused by repetitive movement of the tube within the stoma and can be quickly resolved with properly sizing the tube. In addition, gauze and tape can be used to better secure the tube in position.
Finally, acute stomal bleeding is either prolapsed stomal tissue or upper GI bleeding. Prolapsed gastric tissue has a deeper red color compared to the color of a granuloma, and it is acute not chronic (Figure 1.4b). This distinction is important because silver nitrate would injure the gastric mucosa and should not be used in the setting of gastric tissue prolapse. Prolapse can be treated with the application of salt or sugar to shrink the gastric tissue and then firm and steady pressure to direct the tissue back into the stomal site. If this is unsuccessful, general surgery should be consulted. Significant stomal site bleeding without prolapsed tissue, skin irritation, or granuloma development is upper GI bleeding, until proven otherwise, and should be evaluated by endoscopy.
Figure 1.4 (a) Granuloma notable for its pearly color and irregular shape. (b) Prolapse distinguished from granuloma by the deeper erythema and more uniform shape.
Clogged Tubing
A clogged feeding tube is one of the most common causes for enteric
