Abstract

Introduction: Percutaneous endoscopic gastrostomy (PEG) is an established method of nutrition delivery with a high success rate. Buried bumper syndrome (BBS) is uncommon, but severe complication of PEG placement. In BBS, the internal fixation device (IFD) migrates alongside the tract of the stoma outside the stomach. We report a case of BBS in a patient with Ehlers-Danlos syndrome (EDS) who was found to have a second episode of BBS on esophagogastroduodenoscopy (EGD). This was successfully treated by simple extraction of the buried disc and placement of new PEG tube over a guidewire. Case presentation: A 38-year old female with EDS presented with broken outer tubing of the gastrostomy apparatus. She had severe nausea and bloating, managed with a venting gastrostomy tube. Abdominal exam revealed an obliterated fistula at previous PEG site. The current PEG insertion site appeared healthy with no leak of gastric contents. On EGD, there was a raised mucosal defect at the site of PEG tube tract suggestive of BBS (fig 1). A guidewire was introduced through the PEG tube into the stomach (fig 2), and then the buried bumper was extracted by gentle outward traction. A new 22-French replacement PEG tube was then placed over the guidewire and secured in place by inflating the internal retention balloon (fig 3). Discussion: BBS is caused by excessive compression of tissue between the external and IFD of the PEG tube, leading to outward migration of IFD. With incidence around 1%, BBS is seen more frequently with rigid or semi-rigid IFD. Complications include bleeding, perforation, peritonitis and abdominal abscesses, or phlegmon. The typical symptomatic triad includes an inability to insert, loss of patency and leakage around the PEG. BBS is mostly an incidental finding on EGD and ultrasound is used to assess the depth of migration. PEG with soft or ballooned internal retention devices can be simply extracted. If gentle traction fails, the overgrowing tissue can be released using endoscopic dissection. A disc localized out of the stomach may need surgery. In our case, the patient had a history of BBS two years prior to the current episode. In EDS, the excessive skin elasticity and connective tissue fragility may be responsible for recurrent BBS. Conclusion: Ehlers-Danlos syndrome might be a risk factor for recurrent buried bumper syndrome. Selective cases can be managed simple extraction of the buried disc and placement of new PEG tube over a guidewire.Figure: EGD showing raised mucosal defect over the site of PEG tube tract.Figure: EGD showing a guidewire passing through the PEG tube.Figure: EGD showing internal retention balloon of the newly placed PEG tube.

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