Recurrent Buried Bumper Syndrome: A Rare but Preventable Complication of Percutaneous Endoscopic Gastrostomy (PEG) Tube in an Obese Patient

Abstract

PEG was initially developed in early 1980s and is now the preferred modality for long term enteral access for nutrition. Buried bumper syndrome was first described in 1988 and is a less frequent but a major complication of PEG tube placement. Incidence of buried bumper syndrome is around 0.3-2.4%. We report a 54-year-old female patient with a BMI of 40.37 who needed a long term nutritional access after undergoing tracheostomy. A 20 French PEG tube was placed without any complications. On a follow-up CT scan of the chest in one month, the G-tube internal diaphragm had migrated from the stomach into the abdominal wall musculature consistent with buried bumper syndrome. She was asymptomatic and afebrile. Physical exam was unremarkable without any evidence of erythema or purulence around the PEG tube site. Successful replacement with a 20 French PEG tube was performed endoscopically under direct visualization. A month later, the patient complained of abdominal pain around the tube site along with intermittent oozing of blood through the PEG tube. On examination, tenderness and discharge of secretions was noted around the PEG tube site. As the tract was mature and oral intake was adequate, it was decided to remove the tube. Repeat EGD was performed and PEG tube bumper was not visualized in the gastric cavity. The bumper was noted to have migrated within the tract. Using a guidewire, the PEG tube was safely removed. The defect in the gastric wall at the tract site was closed with placement of endoclips. Complete occlusion was ascertained by successful insufflation of the stomach. Buried bumper syndrome usually occurs due to excessive tightening of the external bumper of the gastrostomy tube against the abdominal wall which creats tension within the gastrostomy tube tract. The internal bumper will eventually erode and migrate through the gastric wall into the abdominal musculature resulting in buried bumper. Obesity is considered to one of the risk factors for buried bumper. In obese patients, alterations in the abdominal pannus during positional changes can create undue tension/friction in the gastrostomy tract thus resulting in migration of internal bumper leading to buried bumper syndrome. This can potentially be prevented by frequent inspection of the PEG tube, adjustment of the external bumper so that the tube is freely rotating, ensure 1 to 1.5 cm space between the bumper and the skin wall and avoid gauze pads between external bumper and the abdominal wall.FigureFigureFigure