Gastrostomy Toolkit

Introduction

Problems around surgically placed feeding tubes are common however many simple steps can be taken to reduce the impact this has on a child. The gastrostomy service based at Southampton Children’s Hospital covers a large region so children and families may have to travel long distances for review by the surgical specialist nurses or the surgical team. The Gastrostomy Toolkit has been created to support staff in both acute hospitals and in the community to manage the most common problems that occur around a surgical feeding tube. This is to avoid unnecessary travel for procedures that can be safely managed closer to home.

Scope & Purpose

For all staff who support children under 18 years of age with a surgical feeding tube. The guideline is a series of flow diagrams designed to help you assess and treat problems with the gastrostomy tube and the exit site (stoma). The aim is to reduce overtreatment and allow for antibiotic stewardship.

Definitions

Gastrostomy: an opening into the stomach from the abdominal wall, made surgically for the introduction of food.

Stoma: an artificial opening made into a hollow organ, especially one on the surface of the body leading to the gut

Granulation Tissue: is new connective tissue and microscopic blood vessels that form on the surfaces of a wound during the healing process

Systemic: affecting the entire body, rather than a single organ or body part.

Cellulitis: infection and inflammation of subcutaneous connective tissue

UHS: University Hospital Southampton Foundation NHS Trust

Guideline

The Toolkit is a series of flow diagrams designed to help you assess and treat problems with the gastrostomy tube and the exit site (stoma). Below is extra information to support the recommendations.

▶Management of a Blocked Tube

Click to expand

Blockage of enteral tubes causes problems both in the acute hospital and in the community. In surgical placed enteral tubes, an attempt must made to resolve the blockage from the existing tube prior to the replacement of the device. Blockage of the feeding tube can result from:

• Inappropriate administration of medications

• Viscous formulas

• Poor flushing techniques

• Partially digested protein

• Aspiration of gastric or intestinal contents

The use of acidic fluids such as cola or pineapple juice has been suggested in the past to unblock an enteral tube. However, the acid can cause the casein in the formula feed to precipitate which will make the blockage worse before it solves the problem. Use of proper flushing technique should prevent most problems. Additional care should be used when administering drugs. In the event of a tube blockage, follow the pathway which uses a stepped process of flushing the tube to attempt to achieve patency.

▶Redness and Infection Pathway

Click to expand

Redness around the skin can be caused by variety of factors.

• Normal inflammatory response post insertion

• Friction from a tube that is too long or too short

• Moisture damage from granulation tissue or leakage from the stoma.

In these scenarios, please treat using the appropriate pathway. If these causes have been ruled out, then you would use the redness pathway that has been developed with the consultant dermatology team here at University Hospital Southampton NHS Foundation Trust (UHS).

In many cases redness as a lone symptom is not indicative of infection and in the interest of antibiotic stewardship, antibiotics should be reserved for the treatment of true infections with symptoms of spreading cellulitis and a temperature. Antibiotics should not be prescribed based on swab results alone as many of these children will have colonisation of tubing or skin surrounding the stoma site. Use of the infection pathway developed by the infectious diseases team here at UHS should guide users on when to swab and treat.

▶Granulation Pathway

Click to expand

This is characterised histologically by the presence and proliferation of fibroblasts, keratinocytes, endothelial cells, new thin-walled capillaries, and inflammatory cell infiltration of the extracellular matrix. The formation of granulation tissue is complex and requires an intricate interplay between the cell types at the wound site.

Over-granulation tissue is believed to occur as a result of an extended inflammatory response, it is an exuberant mass of tissue which sits proud of the epithelium. As the surface is moist it is an excellent medium for bacterial colonization and biofilm formation. It is highly vascularised therefore may bleed easily. The exact mechanism of development is not fully understood although it is thought to develop because of several factors which cause a prolonged inflammatory response. These can include the presence of infection, a reaction to foreign bodies and repeated trauma. Pressure, moisture and friction may also contribute to the development of over-granulation tissue.

Over-granulation tissue:

• Is not harmful

• Is red, moist and bleeds when rubbed

• Oozes a yellow, sticky discharge which dries brown

• Can affect how the device fits in the stoma

• Is common in the first 3 months

There is little evidence or guidance on treatment of over-granulation. Therefore, management has been extrapolated from other specialities and guidelines from other hospital trusts to form our treatment pathway.

Prontosan Solution
This solution is a wound cleanser containing PHMB (polyhexamethylene biguanide) and betaine, suitable for use on acute and chronic wounds. Its formulation consists of a wound irrigation solution that is applied to wounds to moisten, decontaminate, remove exudate, slough and debris. It provides an efficient and effective method of removing of biofilms.

Salt
Studies have shown that salt is effective at treating umbilical granulomas in new-borns. It is thought that the salt draws water out of the cells and causes the granuloma to shrink and dry up. This research has been extrapolated to over-granulation around gastrostomies and Tanaka et al (2013) used salt successfully to treat a small number of paediatric patients with over-granulation.

Steroids
Corticosteroids modify the functions of the epidermal and dermal cells and leukocytes that participate in proliferative and inflammatory skin diseases. Topical steroids can effectively dampen the inflammatory response and reduce the production of over-granulation tissue. Case studies show that steroids can reduce granulation tissue from around gastrostomies but there are side effects if this is used for a prolonged period.

Maxitrol Eye Ointment
This ointment contains dexamethasone, to act as an anti-inflammatory agent on the granulation tissue but is combined with Neomycin and Polymyxin B sulfate which both work on gram negative bacteria helping to reduce colonisation of the skin with an aim to reduce the inflammatory response.

Trimovate Cream
This is a water-miscible cream containing Clobetasone 17-butyrate 0.05% w/w, Oxytetracycline 3.0% w/w as calcium oxytetracycline and Nystatin 100,000 units per gram. It will act as an anti-inflammatory agent like the Maxitrol, but it not only contains an antibiotic but also an antifungal, which is commonly found around gastrostomy sites.

Silver Nitrate
There is literature on the use of silver nitrate to treat granulation tissue, however most described using 75% as also used for treating umbilical granulomas. None of the papers compared the effects of different strengths of silver nitrate applicator sticks on safety or efficacy in treating the granulomas. However, Glynn et al (2011) compared 95% against 75% sliver nitrate for treating epistaxis in children looking at efficacy and pain. In their conclusion they recommend the use of 75% silver nitrate as it appears to be more efficacious, had fewer side effects and is better tolerated. Anecdotal evidence from other specialist nurses found that although 40% silver nitrate is less painful, treatment is less effective resulting in the need for repeated treatments.

Page 1 of 3

Page 2 of 3

Page 3 of 3

▶Discharge from Stoma Site

Click to expand

Page 1 of 4

Page 2 of 4

Page 3 of 4

Page 4 of 4

▶Dilation of Gastrostomy Stoma

Click to expand

▶Unable to Remove a Balloon Gastrostomy Device

Click to expand

Roles & Responsibilities

This guideline applies to all clinical staff employed or contracted by University Hospital Southampton (UHS) Foundation Trust who provide care to children within Southampton Children’s Hospital (edit as appropriate) but can also be used by staff based in the community or in secondary care hospitals. Staff have a responsibility to ensure that they are aware of this guideline and its contents. They should clearly document their rationale if they have not complied with the recommendations detailed in this guideline. It is the responsibility of department managers, consultants, team leaders and education leaders to ensure staff are aware of this guideline. 

Communication & Training Plan

The guideline will be displayed on the Staffnet and the PIER Network website and sent to the relevant Care Group clinical teams. The team leaders will be expected to cascade to all relevant staff groups. All medical and nursing staff caring for children should have support and training in implementing the contents of the guideline. In addition, the guidelines will be included in local induction programmes for all new staff members.

The author is responsible for ensuring the effective dissemination of this guideline. To ensure dissemination takes place and to avoid duplication of work, do not assume others will do this based on their involvement in guideline consultation process.

Methods of dissemination will include:

• Email correspondence

• Communication boards in ward areas for discussion at handover

• Training materials e.g., prompt cards, laminated flowchart

• Consider how you will audit/measure uptake of new guidance 

Process for Monitoring Compliance

The purpose of monitoring is to provide assurance that the agreed approach is being followed. This ensures that we get things right for patients, use resources well and protect our reputation. Our monitoring will therefore be proportionate, achievable and deal with specifics that can be assessed or measured.

Key aspects of this policy will be monitored:

Where monitoring identifies deficiencies, an action plan will be developed to address them.

​Guideline to be reviewed after three years or sooner as a result of audit findings or as any changes to practice occurs.

References

1. Ae R, Kosami K, Yahata S. (2016) ‘Topical Corticosteroid for the Treatment of Hypergranulation Tissue at the Gastrostomy Tube Insertion Site: A Case Study.’ Ostomy Wound Manage. 62(9):52-5

2. BPNG; Administering Drugs via Enteral Feeding Tubes - A Practical Guide Available from: https://www.bpng.co.uk/file.php?f=ZWxlbWVudCMjMTIwIyNmaWxlbmFtZQ==

3. Best Practice Statement (2014) Principles of wound management in paediatric patients. London: Wounds UK. Available to download from: www.wounds-uk.com

4. Borg P, Wilbraham L, Puro P, Vasileuskaya S, Edwards DW, Bell JK, Mullan D, Laasch HU. ‘Use of Flaminal (enzyme alginogel) as a treatment for gastrostomy related stoma complications’ Dept of Radiology, The Christie NHS Foundation Trust, Manchester UK Available from: https://online.fliphtml5.com/qsxip/rymr/?fbclid=IwAR3tUSCeYar7BF1FWnUl8ljwlG6GwMtR8ZU6A9nj96gXtp5OSkbCaLI9nrY#p=1

5. Bradbury S and Fletcher J (2011). Prontosan made easy. Wounds International: Products for Practice, 2(2), pp.1-6. Available from: http://www.woundsinternational.com

6. Bosanquet, D., Rangaraj, A., Richards, A., Riddell, A., Saravolac, V. and Harding, K. (2013). Topical steroids for chronic wounds displaying abnormal inflammation. The Annals of The Royal College of Surgeons of England, [online] 95(4), pp.291–296. https://publishing.rcseng.ac.uk/doi/full/10.1308/003588413X13629960045634?mobileUi=0

7. British Columbia Provincial Nursing Skin & Wound Committee. (2013) ‘Silver Nitrate (AgNO3) Sticks for Wound Care.’ Retrieved from https://www.clwk.ca/buddydrive/file/silver-nitrate-sticks-forwound-care/

8. Frankel EH, Enow NB, Jackson KC 2nd, Kloiber LL. Methods of Restoring Patency to Occluded Feeding Tubes. Nutr Clin Pract. 1998 Jun;13(3):129-131. Retrieved from: https://pubmed.ncbi.nlm.nih.gov/29716151/

9. GBUK Enteral Ltd. (2017). How to use an Enteral ENPLUG if your gastrostomy tube falls out [pdf leaflet]. online. Retrieved from: https://www.gbukenteral.com/pdf/ENPLUG_Literature.pdf

10. Glynn F, Amin M, Sheahan P, Mc Shane D. (2010) ‘Prospective double blind randomized clinical trial comparing 75% versus 95% silver nitrate cauterization in the management of idiopathic childhood epistaxis.’ Int J Pediatr Otorhinolaryngol. 75(1):81-4. Available from: https://pubmed.ncbi.nlm.nih.gov/21093066/

11. Haftu H, Gebrehiwot Gebremichael T, and Gidey Kebedom A. (2020) Salt Treatment for Umbilical Granuloma – An Effective, Cheap, and Available Alternative Treatment Option: Case Report

12. Pediatric Health Med Therapy. 11: 393–397

13. Hossain A, Hasan G, & Islam K. (2012). Therapeutic Effect of Common Salt (Table/ Cooking Salt) on Umbilical Granuloma in Infants. Bangladesh Journal of Child Health, 34(3), 99-102.

14. NMC, Standards for medicines management, London: Nursing and Midwifery Council 2009.

15. Puntis, J. (2009) ‘Benefits and Management of gastrostomy.’ Paediatrics and Child Health, 19(9), pp.415-424.

16. Spruce P, Warriner L, Keast D, Kennedy A. (2012) ‘Exit site wounds Made Easy.’ Wounds International 3(2): Available from: http://www.woundsinternational.com

17. Stumpf JL, Kurian RM, Vuong J, Dang K, Kraft MD. (2014) ‘Efficacy of a Creon delayed-release pancreatic enzyme protocol for clearing occluded enteral feeding tubes.’ The Annals of Pharmacotherapy. 48(4):483-7

18. Tanaka H, Arai K, Fujino A, Takeda N, Watanabe T, Fuchimoto Y, Kanamori Y. (2013) ‘Treatment for hypergranulation at gastrostomy sites with sprinkling salt in paediatric patients.’ Journal of Wound Care. 22(1):17-18