Massive Upper Gastrointestinal Bleeding Due to Buried Bumper Syndrome Treated by Over-the-Scope Clip Placement

Abstract

Introduction: Buried bumper syndrome (BBS) is an uncommon long-term complication of gastrostomy tubes. It results from tight pressure of the external bumper of the tube against the abdominal wall. Due to this pressure, the internal bumper becomes buried within the gastric mucosa and can lodge anywhere between the gastric wall and the skin along the tube's tract. Case summary: A 67-year-old male with a history of tonsillar cancer undergoing chemoradiation therapy was hospitalized with hematemesis and dark output from his gastrostomy tube. He underwent a percutaneous endoscopic gastrostomy (PEG) placement 1 month prior to presentation. The patient's initial vital signs and laboratory studies are shown in figure 1. His abdominal exam showed a PEG in place with no discharge, or bleeding. The patient's hemoglobin dropped from 11.4 to 7.6 g/dl in the first 24 hours. EGD was performed after resuscitation and initiation of pantoprazole intravenously. The EGD showed a large cratered ulcer along the anterior wall of the stomach with the internal PEG bumper buried in the ulcer. Additionally, there was a visible pulsatile vessel overlying the bumper and thus the bumper could not be advanced into the stomach to avoid iatrogenic injury and bleeding. The depth of the ulcer was unable to be assessed as complete visualization was obscured by the bumper (figure 2A). Based on a multi-disciplinary discussion a repeat EGD for an attempted for over-the-scope clip (OTSC) placement was performed. The patient bled again the night following the initial diagnostic EGD. His hemoglobin dropped to 6.6 from 8.8 g/dl. An urgent EGD showed a large clot in the gastric body and within the gastric ulcer bed, but no active bleeding (figure 2B). The patient underwent a third EGD where the PEG tube was successfully removed under endoscopic visualization and a12/6 GC OTSC was successfully used to repair the defect and treat the visible vessel (Figure 3). There was no bleeding at the end of the procedure and the abdomen held air with insufflation. A long 0.035 guidewire was then used to probe around the OTSC site. This confirmed that the clip completely closed the fistula. Conclusion: BBS is considered a delayed complication and failure to recognize it may result in serious consequences. This case demonstrates treatment of BBS complicated by massive bleeding due to a visible vessel from a large ulcer treated by OTSC placement, avoiding potential surgical intervention.2110_C Figure 3. OTSC was successfully used to repair the defect and treat the visible vessel.2110_A Figure 1. The patient's initial vital signs and laboratory studies2110_B Figure 2: A: First EGD showing a large cratered ulcer along the anterior wall of the stomach with the internal PEG bumper buried in the ulcer. A visible pulsatile vessel overlying the bumper. Figure 2B: Second EGD showing a large clot in the gastric body and within the gastric ulcer bed, but no active bleeding.