May 18, 2012
Dear Mayo Clinic:
What is the best treatment for a bleeding granuloma surrounding a stoma? My doctor has tried cryotherapy and cautery, but the bleeding continues and loosens the glue, causing the bag to come away from my body.
Bleeding granulomas are not a common problem for people who have an ostomy. But, as you have found, when they develop, they can sometimes turn into a persistent nuisance. Several other treatment options are available in addition to those you have already tried. If none work, and the granulomas continue to be symptomatic, you may need surgery to revise the stoma.
An ostomy is a surgically created pathway for waste or urine to leave a person's body through the abdomen. An ostomy may be necessary when part of the small intestine or colon has become diseased or damaged and needs to be removed. A stoma is the opening in the abdomen through which waste leaves the body. A bag — sometimes called an appliance — is attached to the stoma to collect the waste.
Granulomas are a type of skin problem that can develop around a stoma. In many cases, these raised, red bumps develop because the ostomy bag is not properly fitted or because the stoma is not raised high enough above the level of the skin. In both situations, waste from the stoma may leak onto the skin, causing irritation, leading to granulomas. An infection can also cause granuloma formation, or they can result from the bag repeatedly rubbing against the skin. In some cases, problems with the skin's healing process after ostomy surgery also can lead to granulomas.
The most effective treatment for granulomas is the topical application of silver nitrate, which creates a mild chemical burn, destroying the granuloma. Applied once or twice a week, when the ostomy bag is changed, this medication can often eliminate or shrink the granulomas. Also, to prevent granulomas from getting worse, it's important that the fit of the ostomy bag be checked to make sure that it is not allowing any leaks. As you mentioned, freezing the tissue affected by granulomas — a procedure known as cryotherapy, or destroying the tissue with heat — called cauterization — can also be treatment options.
For large granulomas or those spread over a wide area, as well as granulomas that bleed or do not get better with other treatments, surgery may be necessary to remove them. Or, if the stoma was not constructed properly in the first place, you may need surgery to re-form it. To ensure that the granulomas do not return after these procedures, it is again very important for the ostomy bag to be refit so the skin is properly covered and waste is not allowed to leak onto it. If none of these approaches work, then the stoma may need to be surgically moved so the skin affected by the granulomas can permanently heal.
Talk to your doctor about other treatment options. Also, if a nurse or another member of your health care team specializes in ostomy fitting and care, talk to that person about steps you can take to help prevent future granulomas. For your long-term health and comfort, it is important that this problem be effectively addressed.
— Eric Dozois, M.D., Colon and Rectal Surgery, Mayo Clinic, Rochester, Minn.