Question: A 75-year-old woman nursing home resident with a history of dementia, recent left middle cerebral artery stroke, tracheostomy, and percutaneous endoscopic gastrostomy (PEG) tube, who was treated with apixaban and clopidogrel was transferred to the hospital for the persistence of severe anemia despite 1 U of packed red blood cell transfusion. On physical examination, she was febrile (38.3°C); her blood pressure (162/56 mm Hg) and her heart rate (62 beats/min) were normal. The abdomen was soft and nondistended with an intact PEG tube without erythema or leakage. Abdominal sounds were normal and rectal examination revealed a large amount of melena. Laboratory tests were consistent with microcytic anemia (hemoglobin 6.1 g/dL) with a high reticulocyte count. International normalized ratio, C-reactive protein, white blood cell count, liver function tests, and pancreatic enzyme levels were all within the normal range. Esophagogastroduodenoscopy revealed a large, semicircumferential, clean-based ulceration extending from the fundus to the antrum along the lesser curvature without high-risk stigmata (Figure A). At the PEG tube site, a 1.5-cm ulcerated tract was seen exiting the gastric wall. The inner bumper of the PEG was not visible and attempts to gently manipulate the tube did not result in visualization of the internal bumper (Figure B). What is the diagnosis and what are next best steps in management? See the Gastroenterology website (www.gastrojournal.org) for more information on submitting to Gastro Curbside Consult. After diagnosis with gastroscopy, a computed tomography scan of the abdomen/pelvis with and without intravenous contrast was ordered to confirm the diagnosis and estimate the depth of migration. It was also done to rule out complications of Buried Bumper Syndrome (BBS; gastrointestinal bleeding, perforation, peritonitis, intra-abdominal and abdominal wall abscesses, or phlegmon) because the patient was anemic and febrile. It revealed a gastrostomy tube bulb in the left rectus abdominis with a patent mucous tract to the stomach lumen (Figure C). The patent mucous tract suggested a mature gastro-cutaneous fistula tract had formed, which generally occurs 2 weeks after PEG tube placement. As seen in the figure, no fluid/abscess surrounding the gastrostomy bulb or tract, extraperitoneal fluid, free air, abscess, lymphadenopathy, or enteric contrast within the peritoneum was seen. This is often a concern with immature gastro-cutaneous fistula tracts within the 2-week window of PEG tube placement. In this case, a mature gastro-cutaneous tract allowed the surgeon to place a new tube in the existing tract during a second endoscopy. The old tube with a soft internal retention device was removed by external traction and the replacement balloon gastrostomy tube was placed over a guidewire without difficulty or risk of peritoneal entry. The patient agreed to publication including images. PEG is a safe and effective means of providing nutrition to patients with neurologic deficits. Complications of dislodgement, dysfunction, infection, and aspiration can occur, especially in patients with altered mental status or dementia, as in this case. BBS is an infrequent complication of PEG tubes that can result in tube dysfunction, gastric perforation, bleeding, peritonitis, or death. Occurrence as early as 6 days has been reported and is associated with increased morbidity and mortality from peritoneal contamination.1Lee T.-H. Lin J.-T. Clinical manifestations and management of buried bumper syndrome in patients with percutaneous endoscopic gastrostomy.Gastrointest Endosc. 2008; 68: 580-584Abstract Full Text Full Text PDF PubMed Scopus (69) Google Scholar Physicians must have a high index of suspicion and should be aware of the historical and physical examination findings that suggest BBS for early diagnosis and appropriate management to avoid serious complications. BBS can be detected by leakage around the PEG, loss of patency, and limited range of motion of the PEG tube either in and out of the tract or lack of free rotation. Patients at increased risk are morbidly obese, have altered mental status, and/or have dementia. Excessive traction by the PEG internal bumper on underlying tissue is the most common etiology of BBS. This results in pressure necrosis and/or migration of the internal bumper in the gastro-cutaneous fistula. Other risk factors for BBS are as follows: cannula (material, shape, and axis deviation); procedure (point of insertion, position of the external fixator, and dressing); long-term care (change of the position of the external fixator, dressing, and preventive maneuvers); and patient (indication, comorbidity, medication, and abnormal manipulation with gastrostomy). A recent classification of BBS severity is based on its mobility and patency with appropriate management approaches.2Cyrany J. Rejchrt S. Kopacova M. Bures J. Buried bumper syndrome: a complication of percutaneous endoscopic gastrostomy.World J Gastroenterol. 2016; 22: 618Crossref PubMed Scopus (79) Google Scholar The management of BBS depends on factors such as the presence of complications, mobility, and patency of the tube, and the depth of internal bumper migration. Although complicated cases may require the creation of a new gastrostomy, in uncomplicated scenarios the buried tubes are removed and replaced with a new feeding tube. A movable and patent tube is managed with only preventive measures and follow-up. In the figure, we have explained the various treatment options for an immovable tube that requires release and dislodgement before replacement (Figure D). The approaches are based on the depth of the buried bumper as assessed with ultrasound. Also, the conservative “cut and leave” approach is only used for patients with dismal prognoses without signs of local or systemic inflammation. A balloon/button gastrostomy can be used as a replacement tube in a well-healed, mature tract. The former is less invasive placement and can be done at the patient’s bedside at home or in the hospital, whereas the button gastrostomy or low-profile gastrostomy tube is used commonly to provide long-term enteral nutrition in younger, more ambulatory patients or in patients who tend to pull at their gastrostomy tubes. In this case, the nursing home patient with dementia either inadvertently pulled the tube or the tube was caught by something and pulled into the abdominal wall. This event likely occurred after the maturation of the PEG tract.2Cyrany J. Rejchrt S. Kopacova M. Bures J. Buried bumper syndrome: a complication of percutaneous endoscopic gastrostomy.World J Gastroenterol. 2016; 22: 618Crossref PubMed Scopus (79) Google Scholar Because the internal bumper was in the abdominal wall and mostly fixed with a patent tract, it was removed with external traction without dissection. This case highlights the need for cross-sectional imaging to confirm suspected BBS in uncooperative patients with altered mental status.3Ayman A.R. Khoury T. Cohen J. et al.PEG insertion in patients with dementia does not improve nutritional status and has worse outcomes as compared with PEG insertion for other indications.J Clin Gastroenterol. 2017; 51: 417-420Crossref PubMed Scopus (34) Google Scholar Alternative approaches include the use of a low-profile device (feeding button) and controlling the movements of such patients. The most important prevention measure is adequate initial positioning of the external bolster when the tract matures (distance of 10 mm between the skin and the external bolster) and repositioning as the stoma tract lengthens with weight gain and in an upright position. In addition, the importance of counseling caregivers regarding post-PEG care for BSS prevention cannot be underestimated. After the tract is mature, once a week they must be instructed to unfasten the external bolster, push the PEG tube a few centimeters inside, and turn it 360° around its long axis before fastening the external bolster again loosely. Also, their regular close examination can help in early detection and treatment of BSS.