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Case Report
Buried Bumper Syndrome Revisited: A Rare but
Potentially Fatal Complication of PEG Tube Placement
Saptarshi Biswas, Sujana Dontukurthy, Mathew G. Rosenzweig,
Ravi Kothuru, and Sunil Abrol
Department of General Surgery, Brookdale University Hospital Medical Center, Brooklyn, NY 11212, USA
Correspondence should be addressed to Saptarshi Biswas; saptarshibiswas@comcast.net
Received September ; Accepted October ; Published January
Academic Editors: C. Diez, Y. Durandy, H. Kern, and Z. Molnar
Copyright © Saptarshi Biswas et al. is is an open access article distributed under the Creative Commons Attribution
License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly
cited.
Percutaneous endoscopic gastrostomy (PEG) has been used for providing enteral access to patients who require long-term enteral
nutrition for years. Although generally considered safe, PEG tube placement can be associated with many immediate and delayed
complications. Buried bumper syndrome (BBS) is one of the uncommon and late complications of percutaneous endoscopic
gastrostomy (PEG) placement. It occurs when the internal bumper of the PEG tube erodes into the gastric wall and lodges itself
between the gastric wall and skin. is can lead to a variety of additional complications such as wound infection, peritonitis, and
necrotizing fasciitis. We present here a case of buried bumper syndrome which caused extensive necrosis of the anterior abdominal
wall.
1. Introduction
Percutaneous endoscopic gastrostomy (PEG) was rst repo-
rted in the literature in as an alternative way to provide
tube feeding for patients without a laparotomy []. Today,
PEG placement is widely accepted as a safe technique to
provide long-term enteral nutrition for a variety of patients
including those with neurologic decits and swallowing dis-
orders and those with oropharyngeal or esophageal tumors
and various hypercatabolic states like burns, short bowel
syndrome, and major traumas []. Although considered a safe
procedure, immediate and delayed complications have been
described with the PEG placement. ese complications vary
from minor complications like wound infections to major life
threatening complications like peritonitis and buried bumper
syndrome. BBS is an uncommon but serious complication
of PEG, occurring in .––% of patients []. We present
here a case of BBS followed by a discussion of its etiology,
management, and prevention.
2. Case description
A -year-old female with multiple comorbidities presented
to the ER from the nursing home with symptoms suggestive
of septic shock. At the time of admission, the patient was
undergoing active treatment for urinary tract infection in the
nursing home. Physical examination of the patient revealed
respiratory distress and hypotension, so emergency intuba-
tion was done and vasopressors started to maintain blood
pressure. Empiric broad spectrum antibiotics were initiated
for septic shock. Patient was then transferred to the medical
intensive care unit for further management.
Patient history revealed that the PEG tube was inserted
one year prior due to dysphagia from a stroke. Upon abdom-
inal examination, the PEG tube was in place in the epigastric
area with signs of edema and erythema on the right lateral
side of the abdomen.
Bullae were spread diusely across the abdomen
(Figure ), and gastric contents were noted to be leaking
around the PEG tube. e patient localized tenderness to
palpation, and bowel sounds were normal with no rebound
or guarding.
e general surgery team was consulted for PEG tube
position and abdominal wall erythema and edema.
Laboratory studies revealed leukocytosis of cells/
cubic mm, hemoglobin of . g/dl, hematocrit of .%, and
an INR greater than as the patient was on regular
Hindawi Publishing Corporation
Case Reports in Critical Care
Volume 2014, Article ID 634953, 4 pages
http://dx.doi.org/10.1155/2014/634953
Case Reports in Critical Care
F : Anterior abdominal wall showing edema, erythema, and
ruptured bullae over the abdomen.
F : CT image of the abdomen. () e solid arrow indicates
dislodgement of the internal bumper of the PEG tube into the
abdominal wall outside the peritoneum. () e hollow arrow shows
subcutaneous collection of uid and air in the abdominal wall.
Coumadin for chronic atrial brillation. Computed tomog-
raphy scan of the abdomen and pelvis was recommended to
conrm PEG tube position and to evaluate for retroperitoneal
hematoma in view of high INR and low hemoglobin. e
nursing sta was subsequently instructed to hold feeding
throughthePEGtubetillitspositioncouldbeconrmedwith
the CT scan.
CT scan of the abdomen showed dislodgement of the
internal button of the gastrostomy tube into the abdominal
wall and a large collection measuring ×. × cm.
e collection showed equal parts of gas and uid density
in the subcutaneous compartment of the right anterolateral
abdominal wall just lateral to the percutaneous gastrostomy
tube outside the muscle and peritoneal reection (Figures
and ).
Aer explaining the benets and risks of the surgical pro-
cedure for drainage in the operating room, the intervention
was denied by the patient’s next of kin. Aspiration of the
subcutaneous collection by the interventional radiologist was
scheduled; however, the plan was withheld due to hemody-
namic instability and the risk of transport to the radiology
suite. A plan was made for bedside incision, drainage, and
debridement of the subcutaneous collection. Vitamin K and
F : CT image of the abdomen. e arrow indicates extensive
subcutaneous collection of uid and air in the abdominal wall.
F : Anterior abdominal wall with erythema and edema prior
to debridement.
FFP was administered for increased INR. Aer explaining the
risks and benets, informed consent was obtained from the
patient’s next of kin.
Bedside debridement was performed, and over
milliliters of foul smelling brownish uid was aspirated from
the wound (Figures and ).euidandthePEGtube
tip were sent for culture and sensitivity. Wound vacuum
was inserted and kept in situ for further drainage (Figure ).
e aspirated uid and PEG tube tip culture and sensitiv-
ity revealed Klebsiella Pneumonia and Candida Vulgaris.
Despite resuscitative eorts, the patient expired days aer
debridement from septic shock.
Wound vac was inserted aer bedside debridement and
drainage. Appropriate antibiotics and antifungals were initi-
ated according to the microbial sensitivity.
3. Discussion
PEG placement complications can be minor ranging from
wound infection around the PEG tub e to major complications
like BBS, necrotizing fasciitis, and colocutaneous stula.
e overall complication rate ranges from % to .%
of cases [–]. ree to % of all cases are aected by
Case Reports in Critical Care
F : Bedside debridement and pulse lavage of the subcuta-
neous collection of the anterior abdominal wall.
F : Wound vac aer debridement for further drainage.
major complications [,,]. e more common minor
complications occur between .% and .% of cases [,,
]. Generally, complications are more likely to occur with
elderly patients, especially those with comorbid conditions,
as well as those with a past history of aspiration []. BBS, rst
described in , is considered a late and rare complication
of PEG placement []. It occurs when the internal bumper
of the feeding tube erodes into the gastric wall leading to
ischemic necrosis and the ultimate migration of the internal
bumper and lodging itself between the gastric wall and the
skin. A relationship is believed to exist between tightening
of the external bolster in an eort to prevent leaking of
gastric contents causing increased tension in the tube [].
Other contributing factors include gastric acid alteration of
the internal bumper, PEG tube characteristics such as a hard
plastic composition, and inadequate patient care [].
Although many risk factors like obesity, rapid weight
gain, patient manipulation, gauze placement beneath the
external bumper instead of over it, chronic cough, tube
manipulation by inexperienced personnel, and malnutrition
have been associated with BBS, obesity is considered as the
single most important risk factor for this syndrome []. It
can be ascertained that any unnecessary increased tension
of the tube can lead to BBS over a period of time. While
the earliest reported complication occurred at days aer
insertion, in a range of – months the majority of BBS occur
with a median of months [,]. Ultimately, the migration
oftheinternalbolstercanleadtoalossoffeedingaccessanda
variety of other minor and major complications as previously
discussed. Patients with this syndrome typically present with
leakage around the PEG tube or signs of infection like edema
or erythema, an immobile catheter, and abdominal pain
or resistance to administer formula infusion. Diagnosis of
BBS is made clinically and conrmed endoscopically or with
computed tomography [].
e mainstay of treatment for these patients includes the
removal of the buried bumper, even in the asymptomatic
patient in order to avoid further complications such as
stomach perforation, peritonitis, and infection of the sub-
cutaneous tissue []. Various internal techniques including
surgery or endoscopic snare retrieval through the mouth
canbeimplementedfortuberemoval[,]. Oen times,
simple external traction is possible with a collapsible inter-
nal bumper []. Additional techniques are currently being
described such as using an angioplasty balloon dilator under
radiological guidance to avoid surgery [].
While the current literature lacks strong evidence to
support a specic preventive practice, possible considerations
have been suggested. Among these are allowing for an
additional .– cm between the external bumper and the
skin, gently rotating and manipulating the PEG in and out
daily, and measuring the length of the external portion of the
tube in order to recognize migration and avoid unnecessary
tube traction [,].
4. Conclusion
BBS is a rare and typically late presenting complication of
PEG tube placement. Early recognition of this complica-
tion reduces the life threatening consequences involved. A
multidisciplinary team approach and patient education are
essential eorts for preventing BBS.
Conflict of Interests
e authors of this paper have no conict of interests or any
nancial gain.
Acknowledgments
e authors would like to thank Clarence Ojo, M.D., and Tak-
Keung Wong, M.D., for their invaluable assistance with this
case report.
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