Internal Bumper Research Articles

Prospective randomized controlled trial comparing a novel and dedicated device with conventional endoscopic techniques for the treatment of buried bumper syndrome (with video)

Buried bumper syndrome (BBS) is a rare adverse event of PEG tubes. This study compared the newly developed Flamingo device (Fujifilm Medwork GmbH, Höchstadt, Germany) with conventional endoscopic techniques for BBS treatment. This prospective, randomized controlled trial compared the Flamingo set (study group) with other endoscopic techniques (control group) for BBS treatment in 6 German hospitals. The primary endpoint was procedure time. Further outcome parameters were technical success, adverse event rate, and number and cost of devices used in each group. Thirty-six patients (18 in each group; mean age, 73 years; 12 women) were included in this study between March 2018 and December 2022. Median time since placement of the feeding tube was 30 months. The bumper was located in the gastric corpus in 27 patients, and the internal bumper was completely overgrown in 31 patients. The duration of the removal procedure was 17 minutes (range, 3-72) in the study group compared with 38 minutes (range, 12-111) in the control group (P= .046). The primary technical success rate was 77.8% in the study group and 55.6% in the control group (P= .157), whereas the overall technical success rate was 100% compared with 83.3% (P= .070). Adverse events occurred in 4 patients (11.1%). Endoscopic removal of the buried bumper using the Flamingo device was significantly faster than that with other endoscopic techniques and showed a higher technical success rate. This device may become the endoscopic treatment of choice for BBS. (Clinical trial registration number: NCT03186066.).

WEO Newsletter.

WEO Newsletter.

S3691 Where Is the Bumper? A Case of Percutaneous Endoscopic Gastrostomy (PEG) Tube Malfunction

Introduction: Percutaneous endoscopic gastrostomy (PEG) tubes are used for enteral access in patients requiring nutritional support. PEG tube placement and removal generally are regarded as safe procedures. However, complications can be experienced in 16-70%, ranging from benign pneumoperitoneum to gastric outlet obstruction, buried bumper syndrome, and bowel perforation. Our case describes a retained internal bumper during PEG tube removal that undergoes spontaneous passage. Case Description/Methods: Our patient is a 71-year-old male with a past medical history of tongue cancer treated with chemoradiation and subsequent dysphagia due to esophageal strictures necessitating PEG tube placement. He presented to the hospital with nausea, recurrent emesis, and an inability to tolerate tube feeds. His PEG tube was placed to gravity with one liter of output and relief of symptoms. A plan was made to proceed with gastrojejunostomy (G-J) tube to mitigate his symptoms. During bedside removal of his PEG tube, the internal bumper was noted to no longer be attached to the tube (Figure 1A). A Foley catheter was placed in the tract to maintain its patency. As the bumper was presumed to be retained in the stomach, esophagogastroduodenoscopy was performed but there was no evidence of foreign body throughout the exam. A computed tomography scan of his abdomen was obtained urgently and showed passage of the bumper into the jejunum (Figure 1B). Serial abdominal radiographs were obtained over the following day showing migration of the bumper into the rectum and was subsequently passed in his stool. Thereafter, the patient has successfully G-J tube placement by interventional radiology. His tube feeds were advanced to goal rate and the patient was no longer having any nausea or vomiting. Discussion: Retained PEG tube internal bumper is a rare complication of PEG tube removal. Prior case reports have described bumper migration into the small bowel where it became lodged and resulted in small bowel obstruction. At least one prior case resulted in small bowel perforation. In cases of bowel obstruction, surgical intervention is warranted. However, in most cases this complication simply warrants clinical monitoring for evidence of obstruction or passage of the PEG bumper; in most reported cases, endoscopic retrieval was not attempted or feasible, and resolved via spontaneous bumper passage through the gastrointestinal tract.Figure 1.: (A) PEG tube with internal bumper no longer attached. (B) CT scan of abdomen showing PEG tube bumper in the jejunum (orange arrow).

An Incidental Discovery of a Serious Complication

An Incidental Discovery of a Serious Complication

EP-642 Case Report: Using the Novel Flamingo Device for Endoscopic Treatment of Buried Bumper Syndrome in high risk patients

Abstract Aim Buried Bumper Syndrome is a rare, major late complication of percutaneous endoscopic gastrostomy (PEG) occurring in 1% of cases. It occurs when the internal bumper of the PEG tube erodes into the gastric wall. This lead to a loss of patency, leakage and inability to change the tube endoscopically. Until recently, the treatment was surgical removal under general anaesthesia. However, patients with BBS are likely to have significant co-morbidities thus deeming the procedure high risk. Method We present a case report demonstrating successful treatment of BBS completed endoscopically using the Flamingo device with a good patient outcome. The Flamingo device is a new endoscopic tool that acts like a sphincterotome. Appropriate consent was taken from the patient. This was performed on a 56 year old patient suffering from multiple sclerosis causing dysphagia for which a PEG tube was inserted in 2018 for nutrition. Over time, his care home noticed significant leakage from the site. At gastroscopy, he was diagnosed with BBS. Due to his risk for surgical intervention, the Flamingo device was trialled to remove the buried bumper and allow insertion of a new PEG. Results As demonstrated in the photos, the mucosa was successfully cut allowing the buried bumper PEG to be retrieved. A new PEG was inserted without complication. The patient was discharged the following day and no complications have arisen 3 months later. Conclusion The Flamingo device has proven to be a safe and minimally-invasive method to treat BBS endoscopically in this patient.

Unusual application of an endoscopic-laparoscopic rendezvous technique to restore the percutaneous gastrostomy in buried bumper syndrome.

A 66-year-old man with cerebrovascular disease underwent placement of a percutaneous endoscopic gastrostomy (PEG) using a 20-Fr dome-bolstered tube. After 1-month, the patient was admitted to our institute for investigation of infusion resistance and leakage around the tube. On physical examination, the internal bumper was not rotatable or moveable, and was subcutaneously palpable. A computed tomography scan confirmed dislocation of the peritoneal bumper ([Fig. 1 a]). Endoscopically, just a small dimple was visible in the mucosa of the anterior wall of the stomach ([Fig. 1 b]), confirming the diagnosis of complete buried bumper syndrome. The PEG was removed with gentle external traction.

A rare cause of GI bleed

A 67-year-old female with a history of pancreatic cancer with gastric outlet presented with maroon-colored bleeding from the percutaneous endoscopic gastrostomy (PEG) tube for 1 day. On examination, necrotic tissue with surrounding cellulitis was noticed around the PEG tube insertion site, and the internal bumper of the tube was palpated superficially under the skin. Imaging demonstrated an abnormally migrated bumper just beneath the skin. Buried bumper syndrome is a rare complication of in situ PEG tube, and in this article, we present the clinical images of a patient and discuss briefly the risk factors, diagnosis, and management of the condition.

A Rare Finding of Gastric Metastasis From Tonsillar Squamous Cell Carcinoma.

A 61-year-old Caucasian man with tonsillar squamous cell carcinoma (SCC, stage T2N1, diagnosed 1 year ago) underwent an endoscopic percutaneous gastrostomy tube (PEG) placement for oropharyngeal dysphagia at the time of diagnosis. Given pulmonary metastases, he was begun on immunotherapy. Upper endoscopy was scheduled for PEG tube replacement. He denied abdominal pain, melena, and hematochezia. Hemoglobin was 11.6 g/dL. The upper endoscopy found a 3-cm ulcerated mass along the greater curvature of the gastric body (Figure A and Figure B). This was located 2 cm away from the internal PEG bumper. He underwent an uneventful PEG replacement. Biopsies demonstrated SCC (Figure C), with staining positive for p40 (Figure D). This established the diagnosis of gastric metastasis of tonsillar SCC. He was continued on immunotherapy. Head and neck SCC metastasize to the lung, bone, and liver. We demonstrate here one of the few reported cases of tonsillar metastases to the stomach, which is one of the least common primary malignancies that result in gastric metastases. Although our patient did not have metastases at the gastric stoma, PEG tubes have been suggested as a risk factor for distal seeding of metastases. Gastroenterologists should consider direct PEG placement instead of pull-through placement in such patients.View Large Image Figure ViewerDownload Hi-res image Download (PPT)View Large Image Figure ViewerDownload Hi-res image Download (PPT)View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Buried bumper syndrome: A late complication of PEG tube insertion.

The identification of BBS is crucial to avoid serious complications including sepsis and peritonitis. The diagnosis can be made clinically or from endoscopy. The exact site of the migrated PEG internal bumper can be demonstrated on imaging study.

Buried bumper syndrome: prevention and management in the community

Percutaneous endoscopic gastrostomy (PEG) is a well-established form of artificial nutrition. Buried bumper syndrome (BBS) is a rare but severe complication related to this type of feeding tube. BBS is described as when the internal bumper migrates into the stoma tract and/or the mucosa, and the inner lining of the stomach starts to grow around and over the internal bumper. It can result in pain, infection and the loss of the feeding tube as a port of entry for delivery of nutrition, hydration and medication into the stomach. When suspected, BBS requires urgent referral into specialist hospital services. It is somewhat preventable with appropriate aftercare; however, incidents do occur. The evidence and guidance on care of PEGs differs, and more data and research are needed into the incidence of BBS and what influences it. Access to appropriate nutrition support teams is essential to support patients and their caregivers with all aspects of enteral feeding.

May chronic cough in chronic obstructive pulmonary disease be a contraindication of Percutaneous Endoscopic Gastrostomy placement: a case report

BackgroundPercutaneous Endoscopic Gastrostomy (PEG) can involve some complications, despite the good safety of its track record. The Buried Bumper Syndrome (BBS) is a rare, late and dangerous complication that consists in the erosion of the internal bumper through the gastric wall.Case presentationWe report the development of BBS in a man with chronic obstructive pulmonary disease (COPD) who had a persistent chronic cough which was prevalently but not solely in the morning and required placement of a PEG tube for continuous infusion of Levodopa/carbidopa intestinal gel for advanced Parkinson's disease.ConclusionWe believe that COPD with chronic cough while not representing an absolute contraindication to PEG placement, may potentially cause BBS and therefore an appropriate regimen of tube care by expert personnel is mandatory in this setting.

Multicenter cohort study of patients with buried bumper syndrome treated endoscopically with a novel, dedicated device

Buried bumper syndrome (BBS) is a rare adverse event of percutaneous endoscopic gastrostomy (PEG) placement in which the internal bumper migrates through the stomal tract to become embedded within the gastric wall. Excessive tension between the internal and external bumpers, causing ischemic necrosis of the gastric wall, is believed to be the main etiologic factor. Several techniques for endoscopic management of BBS have been described using off-label devices. The Flamingo set is a novel, sphincterotome-like device specifically designed for BBS management. We aimed to evaluate the effectiveness of the Flamingo device in a large, homogeneous cohort of patients with BBS. A guidewire was inserted through the external access of the PEG tube into the gastric lumen. The Flamingo device was then introduced into the stomach over the guidewire. This dedicated tool can be flexed by 180 degrees, exposing a sphincterotome-like cutting wire, which is used to incise the overgrown tissue until the PEG bumper is exposed. A retrospective, international, multicenter cohort study was conducted on 54 patients between December 2016 and February2019. The buried bumper was successfully removed in 53 of 55 procedures (96.4%). The median time for the endoscopic removal of the buried bumper was 22 minutes (range, 5-60). Periprocedural endoscopic adverse events occurred in 7 procedures (12.7%) and were successfully managed endoscopically. A median follow-up of 150 days (range, 33-593) was performed in 29 patients (52.7%), during which no significant adverse events occurred. Through our experience, we found this dedicated novel device to be safe, quick, and effective for minimally invasive, endoscopic management of BBS.

S2985 Gastric Outlet Obstruction Due to Malposition of Gastrostomy Tube – A Rare and Commonly Misdiagnosed Condition

INTRODUCTION: Gastrostomy tube (GT) insertion is an established method for providing enteral access for long-term nutrition. However, GT placement is associated with several complications. An uncommon, and often initially misdiagnosed, complication is gastric outlet obstruction (GOO). Rarely, migration and malposition of a GT can lead to this condition. Often, simple adjustment of the tube can lead to resolution of the patient’s clinical condition and prevent needless medical tests, overly aggressive management, and further complications. Here, we present a case of GOO after unintended migration of a GT. CASE DESCRIPTION/METHODS: A 55 y/o nursing home F had a PMH of stroke, post-stroke dysphagia with GT placement, HTN, DM, and chronic respiratory failure. For one week, she had intermittent non-bilious vomiting after GT feedings. Her vital signs were stable. On physical exam, she was in no distress. Per her baseline, she was awake, alert, non-communicative, and did not respond to verbal cues. She was breathing comfortably with oxygen delivered by Venturi mask through a tracheostomy. The abdomen was benign. The gastrostomy site was clean, dry, intact, and free of erythema, drainage, and exudate (Figure 1). However, the GT had migrated into the abdomen up to the 18-cm mark at the skin level. Moreover, there was resistance to attempts to reposition the GT percutaneously. A plain abdominal x-ray and labs were unremarkable. A contrast study of the GT revealed contrast extrusion into the duodenum but no contrast in the stomach (Figure 2A). The inflated internal balloon of the GT had migrated distally and become trapped in the duodenum, thus causing a functional GOO. And so, the internal balloon of the GT was deflated, the GT was repositioned by pulling back and withdrawing it into the stomach, the internal balloon was inflated again, and the GT was secured to the abdominal wall with the external retainer at the 3.5-cm mark. A repeat contrast study revealed contrast in the stomach and the duodenum, confirming the location of the distal tip of the GT in the stomach (Figure 2B). Enteral GT feedings were resumed and she tolerated them well. DISCUSSION: Irrespective of the type of GT, whether it is of bumper or balloon type, if the inflated internal balloon or internal bumper is allowed to migrate through the pylorus, it can cause mechanical obstruction (Figure 3). This can be avoided by confirming that the external retainer is positioned appropriately. Prompt, safe management can lead to resolution of the patient’s clinical condition.Figure 1.: (A, B). The gastrostomy site is clean, dry, intact, and free of erythema, drainage, and exudate. The tube has migrated into the abdomen. The 18-centimeter mark at the skin level is visible.Figure 2.: (A, B). Contrast studies and abdominal x-rays, before and after repositioning of the gastrostomy tube. (A) There is contrast extrusion into the duodenum but no contrast in the stomach. The inflated internal balloon of the gastrostomy tube has migrated distally and become trapped in the duodenum, thus causing a functional GOO and duodenal obstruction. (B) There is contrast in the stomach and the duodenum, confirming the location of the distal tip of the gastrostomy tube in the stomach.Figure 3.: (A) The bumper type of gastrostomy tube (B) The balloon type of gastrostomy tube During tube placement, a gastrocutaneous tunnel is created and a tube with either an internal bumper or an internal balloon is inserted. The bumper or inflated balloon remains in the stomach to prevent the expulsion of the gastrostomy tube. The external retainer keeps the bumper or balloon in close contact with the inside wall of the stomach and also helps to keep the abdominal and stomach walls in apposition for future formation of a mature track.

Visualization of Buried Bumper Syndrome With Upper Endoscopy

An 82-year-old woman with small-bowel resection and percutaneous gastrostomy (PEG) tube insertion for mesenteric ischemia 2 months ago was admitted for anemia. Her hemoglobin level was 8 g/dL with no overt gastrointestinal bleeding. Upper endoscopy visualized erosion of the internal gastrostomy bumper through the wall of the gastric body (Figures A and B), consistent with buried bumper syndrome. No other gastric or duodenal ulcers were identified. Computerized tomography located the bumper in the anterior abdominal wall, not entirely within the stomach (Figures C and D).

2731 Duodenal Pressure Ulcer Secondary to Migratory PEG Tube

INTRODUCTION: Percutaneous endoscopic gastrostomy (PEG) tubes allow for long-term nutritional support in patients with preserved gastrointestinal function and dysphagia. The procedure and long-term presence of a PEG tube is well tolerated, with a complication rate of 0.4% to 4.4%. Adverse events include infection, skin breakdown, and aspiration. Upper GI bleeding, secondary to gastric or duodenal pressure ulcers is a rare complication. We present a case of duodenal pressure ulcers secondary to a PEG tube, along with a review of the literature and a proposed mechanism for this injury. CASE DESCRIPTION/METHODS: A 94-year-old non-verbal woman with a history of dementia and oral squamous cell carcinoma presented to the ED for RLQ abdominal pain. She was found to have leakage around the replacement PEG tube. Given comorbidities, patient was initially managed conservatively, but eventually underwent an endoscopy (EGD) due to persistent melena and down trending hemoglobin. The EGD demonstrated that the intragastric retention balloon had migrated beyond the pyloric channel resulting in a partial gastric outlet obstruction. The balloon was deflated revealing a large nonbleeding duodenal pressure ulcer. Since no stigmata of bleeding were identified, the replacement PEG was removed and new mushroom catheter and internal bumper was placed through the original tract. The patient was placed on an IV PPI to allow for adequate healing and melena resolved. DISCUSSION: Standard replacement PEG tubes are secured with an external bumper on the skin with an intragastric saline filled balloon. Ideal distance between the retainer and skin is 1-2 cm. If a PEG balloon is pulled too tightly there is a risk for pressure ulcer formation at the gastrostomy site. Conversely, if the PEG tube is too loose there is the risk of PEG balloon migration. With intense gastric peristalsis, the saline-filled balloon can migrate through the stomach, pylorus, and into the duodenum. While this is rare, case reports of gastric and duodenal outlet obstruction have been observed. In this case, the migration of the balloon into the duodenum led to a partial gastric outlet obstruction leading the patient to present with leakage, pain, melena, and anemia due to a large duodenal pressure ulcer. Proper PEG placement and care should be the main source of pressure ulcer prevention, and this rare complication should be considered in patients with melena and anemia.

1865 Gastric Perforation During PEG Tube Placement in ALS Patient With Severe Malnutrition

INTRODUCTION: The natural progression of amyotrophic lateral sclerosis (ALS) usually leads to malnutrition because of decreased oral intake from dysphagia, reduced salivation, and anorexia. A decrease in weight of 5-10 kg or BMI < 20 requires intervention to improve nutrition. Intervention includes placing a feeding gastrostomy surgically, endoscopically (percutaneous gastrostomy or PEG), or radiologically. Complications range from dislodgement to parietal necrosis and death. This case involves a patient with severe malnutrition who had a significant gastric perforation during PEG tube placement, which we attribute to a patient’s nutritional status and mucosal/muscular atrophy. CASE DESCRIPTION/METHODS: 80 yr-old man with PMH of end-stage ALS presented to the hospital for failure to thrive and significant weight loss. He underwent an EGD for PEG tube placement. During the EGD, the gastric body was notable for diffuse atrophic mucosa and hiatal hernia. Using standard technique, a 20 Fr EndoVive Safety gastrotomy tube was safely pulled through the mouth using guidewire into the stomach. The trocar needle was removed, and the PEG was pulled out from the stomach through the skin. When confirming position of the PEG tube by relook endoscopy, we found a 4 cm perforation in the stomach at the diaphragmatic hiatus with associated hemorrhagic mucosa. At which point, a large amount of subcutaneous emphysema was seen in the chest and neck. The gastroscope was immediately withdrawn, and surgery was called. The patient was transferred to the ICU. After a discussion with surgery, patient, and his family, they agreed to palliative care as patient adamantly refused further procedures. The patient was transferred to hospice care and expired three days later. DISCUSSION: This case is a rare presentation of a severe complication during PEG tube placement that we attributed to the poor nutritional status of the patient. We believe that the gastric mucosa and muscular atrophy from severe malnutrition led to the large perforation when the guidewire or the internal bumper of the PEG transversed the diaphragmatic hernia. This is the first case describing a complication of PEG tube placement in a severely malnutritioned ALS patient. In conclusion, this case highlights the possibility of altering procedural techniques for PEG tube placement and the necessity for increased caution during PEG tube placement in ALS patients with severe malnutrition.

3126 Buried Bumper Syndrome

INTRODUCTION: Feeding tube placement ensures appropriate delivery of enteral nutrition,however is associated with adverse effects which can occur at rate as high as 10%. Complications may be minor or fatal including death. Common complications include aspiration, wound infection, bleeding, perforation, necrotizing fasciitis and intestinal obstruction. Our case is a very rare early presentation of life threatening buried bumper syndrome. CASE DESCRIPTION/METHODS: 56 year old Caucasian Male with history of benign esophageal stricture status post percutaneous gastrostomy tube (PEG) placement in 2016 and history of Bipolar disorder brought in by from nursing home to Emergency department for dislodgement of his PEG tube and complaint of abdominal pain and drainage from his gastric stoma. Interventional radiology attempted fluoroscopic guided PEG placement procedure, however procedure was aborted because an opacified contrast was noted in gastric lumen, which was suspicious for retained gastrostomy bumper. Further imaging was obtained with CT Abdomen/pelvis that revealed a metallic density projecting from the skin of the anterior abdominal wall to within the body of the stomach. Upper Endoscopy was subsequently performed but was limited due to a pinpoint stricture of esophagus was noted 30 cm from the incisors which could not betraversed by the upper endoscope. Laparoscopic removal of the buried bumper was performed with subsequent laparoscopic gastrostomy tube placement. Surgery and pathology report showed removed foreign body from stomach stated medical device consistent with gastric tube. Patient had successful removal of retained bumper with new placement of PEG tube. Patient tolerated procedure well without complication. DISCUSSION: Buried bumper syndrome is caused by migration of the internal bumper of the PEG into the gastric or abdominal wall. BBS presentation on average approximately is 18 months, depending on which kind of feeding tube has been used. Unfortunately, buried bumper syndrome presents with late stage and early presentation are usually rare. Implementation of post PEG placement follow up policies could have an impact in preventing these PEG tube related fatal complications. To our knowledge there are no guidelines, which recommend an interval of time for follow-up post PEG placement to assess for complications. We suggest that an optimal close follow up concord by each institution for status post PEG placement may prevent and minimize serious complication and provide better patient care.

Transhepatic PEG Tube Placement

A 50-year-old man was successfully treated for severe acute respiratory distress syndrome from adenovirus pneumonia with venovenous extracorporeal membrane oxygenation. Because of the inability to wean from the ventilator, tracheostomy and percutaneous endoscopic gastrostomy (PEG) tube insertion were performed. During PEG tube insertion, 1:1 finger movement was visualized; however, transillumination was not. A percutaneously placed guidewire was grasped endoscopically from the gastric lumen and brought out through the mouth, where the PEG tube was attached and inserted orally through to the skin in a single pass. Eight days after PEG insertion, hemoglobin decreased significantly, and computed tomography scan revealed a spontaneous thigh hematoma caused by anticoagulation. The PEG tube was incidentally noted to pass through the lateral tip of the left lobe of the liver, without intra-abdominal bleeding (Figure A, green circle). A surgical consultation was obtained, but no intervention was recommended. The patient’s swallowing progressively improved, and the PEG tube was successfully removed after 6 months of use. The internal bumper was snared and removed endoscopically to prevent transhepatic passage of the bumper, after freeing by cutting the external portion of the tube. This adverse event may be prevented by performing the safe track technique or by surface ultrasound-guided landmarking.

A novel device for the endoscopic management of buried bumper syndrome

Buried bumper syndrome (BBS) is a complication of percutaneous endoscopic gastrostomy (PEG) in which the internal bumper is overgrown by the gastric mucosa. Apart from loss of patency of the PEG tube, the buried bumper may evoke symptoms such as abdominal pain or peritubular leakage. While the management of an incompletely buried bumper is fairly straightforward, this is not the case for a completely buried bumper. Different approaches to remove completely buried bumpers have been described, including endoscopic knife- or papillotome-based techniques. However, these devices are used off-label and the procedures can be laborious. The Flamingo device has recently been introduced as the first tool specifically designed to remove a completely buried bumper. We describe the technique and our first experience in five patients with a completely (n = 4) or almost completely (n = 1) buried bumper. Fast and save removal of the buried bumper was obtained in all patients. We believe that this device has the potential to become the standard first-line tool for the management of completely buried bumpers.

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

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.