Acute Buried Bumper Syndrome

Abstract

Purpose: Introduction: Acute Buried Bumper Syndrome (BBS) is an unusual complication of percutaneous endoscopic gastrostomy (PEG) tube placement that can be lethal if not recognized early on. We present a case of BBS occurring in just six days. Case Report: An 85-year-old male underwent an uneventful Boston Scientific PEG tube placement for feeding purposes after he was diagnosed with stage 2A esophageal Adeno CA. Six days later he presented with worsening abdominal pain and inability to infuse feedings through the tube. Examination revealed erythema and induration at the PEG tube site with the tube in place at about 2 cm mark. Rest of the physical exam and routine laboratory testing was unremarkable. Abdominal CT-scan revealed that the button of gastrostomy tube had migrated up in the abdominal wall within the peritoneal cavity ventral to the stomach. A diagnosis of acute BBS was made, and the patient was treated with PEG tube removal and broad spectrum antibiotics. The PEG site improved and on day seven of admission, a replacement G-tube using a guide wire and the original tract, was placed by Interventional Radiology. The patient recovered uneventfully. Discussion: Buried bumper syndrome is an unusual complication of PEG tube that occurs when the internal bumper migrates and becomes lodged anywhere between the gastric wall and the skin along the PEG-tube track. Endoscopy is considered the most definite test. Although not always needed, ultrasound, computerized abdominal tomography, and magnetic resonance imaging can be helpful in the diagnosis. Excessive tension between the internal and external bumpers causing gastric ulceration at the bumper site is thought to be the initiating factor in BBS. It is usually considered to be a late complication, but cases occurring within one to two months have been reported. Treatment recommendations include removal of the buried bumper, even in the asymptomatic patients, to avoid further complications. In cases where a patient presents with an abdominal wall abscess, it may not be possible to place the replacement tube through the same tract.Figure: CT scan showing internal bumper in the abdominal wall within the peritoneal cavity.