Vol 43 # 2 June 2011 - Kma.org.kw

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150 KUWAIT MEDICAL JOURNAL June 2011 Case Report Buried Bumper Syndrome Abdullah Al-Muhaiteeb , Sahasranamaiyer Narayanan Department of Internal Medicine, Al-Amiri Hospital, Kuwait Kuwait Medical Journal 2011; 43 (2): 150-152 ABSTRACT Percutaneous endoscopic gastrosomy is becoming a common and widely accepted procedure for its safety and efficiency. In this case report, we describe a complication, called buried bumper syndrome (BBS) which is becoming more frequent among patients, who have percutaneous endoscopic gastrosotmy (PEG) tube inserted. BBS can be serious, even fatal in some cases. We report here, a 42-yearold lady with suprasellar meningioma who developed BBS, one and half year post-PEG-tube insertion. She started to have abdominal pain and distension, PEG tube blockage and eventually PEG site infection. The PEG tube could not be removed endoscopically and it was removed surgically instead because the PEG tube was buried beneath the gastric mucosa and in the abdominal wall. KEY WORDS: complication, gastrostomy, migration, PEG INTRODUCTION Percutaneous endoscopic gastrosotmy (PEG) was first introduced in 1979 to provide enteral feeding in children and young adult. Currently, PEG feeding is the preferred device recommended by the American Gastroenterological Association (AGA) for providing long-term enteral nutrition for patients, who are not receiving adequate amount of food orally [1] . It has been more widely used, particularly over the last few years in order to provide long-term nutritional support to patients unable to maintain an adequate oral intake. As any other procedure, PEG placement has several complications, which can occur during the insertion of the PEG tube or after. There are number of complications that are associated with PEG placement such as aspiration, hemorrhage, peritonitis and gastrocolocutaneous fistula. In this brief article, we focus on a complication of PEG tube called buried bumper syndrome or BBS, which was considered rare earlier, but is becoming more common [2] . As physicians, we should be aware of this complication that might result in patient’s death, if not managed appropriately. BBS is defined as the migration of the internal bumper of the PEG tube from the gastric lumen and its getting lodged in the gastric wall or anywhere along the gastrostomy tract. CASE REPORT A 42-yearold woman was diagnosed with suprasellar meningioma (grade 1) in 2007, which required craniotomy and total excision of the meningioma. Postoperatively, she developed a stroke that made her dysphasic, blind and affected her swallowing ability. Therefore, PEG tube was placed in Germany. In Jan 2009, she developed abdominal distension. This was mainly seen during feeding time. She also seemed very uncomfortable during her feed. She had generalized abdominal tenderness. Gastroenterology team was consulted. The initial impression was that the tube was blocked. However, the PEG tube bumper was not seen endoscopically (Fig. 1) and BBS was diagnosed. Several attempts were made by the gastroenterologist to remove the PEG tube by manual traction as well as by endoscopy. Unfortunately, the tube could not be removed by endoscopy and required surgical removal. It was decided to re-endocope the patient to assess the tube status and the presence of BBS. Endoscopy was done in the presence of the surgical team to assess the tube status. Saline was injected during the procedure and it was coming freely into the gastric lumen (Fig. 2). As a result PEG tube feeding was re-started, as suggested by the surgeons. Unfortunately, the patient developed fever and profuse sweating within 48 hour after feed re-initiation. Pus from PEG tube site was seen. Intravenous antibiotic was started and septic screen was obtained including a swab from the tube site. PEG tube swab culture showed Staph. aureus and Staph. epidermidis. Address correspondence to: Dr Abdullah Al-Muhaiteeb, MBchB, Department of Internal Medicine, Al-Amiri Hospital, Kuwait. Tel: 99626522, E-mail: dr.muhaiteeb@hotmail.com
June 2011 KUWAIT MEDICAL JOURNAL 151 Fig. 1: Showing the gastrostomy opening with the absence of the internal bumper indicating buried bumper syndrome After a re-evaluation with the gastroenterologist, the surgeons agreed to remove the tube. The tube was removed with no complication. There was no need to insert another PEG tube as the patient was regaining her ability to swallow and was taking her food orally. DISCUSSION The migration of the internal bumper into the gastric mucosa or abdominal wall as complication of PEG tube insertion was first described in 1988 [3] . Later, it was called ‘’Buried Bumper Syndrome’’ by Klein [4] . BBS often manifests months to years after PEG tube placement. It presents as abdominal pain mainly during feeding time, difficulty feeding or flushing the tube, and inability to move or rotate the tube because the internal bumper may have been well-buried beneath the gastric mucosa. Nevertheless, BBS has been rarely reported to present as malena resulting in fatal consequences [5] . BBS is considered as an uncommon complication occurring in 1.6% of patients with PEG replacement [6] . However, a study from Taiwan suggested that BBS is not that uncommon as previously thought. In addition, it suggested that BBS can occur soon after tube insertion [2] .This is possibly due to the increasing number of patients with PEG tube. BBS most commonly is suspected by physical examination. Ultrasound, contrast radiography, computed tomography or magnetic resonance imaging are usually unnecessary in clinical practice. This complication is usually confirmed endoscopically, as in our case. As physicians with increasing number of patients with PEG tube, it is very important for us to recognize that once BBS is diagnosed, the PEG tube should be removed even if the patient is asymptomatic, because the tube may continue to migrate until it is completely buried in the abdominal wall and that itself may lead to very serious complications such as sepsis, peritonitis, stomach perforation and bleeding. BBS most likely occurs as a result of excessive tension between the internal and external bumpers leading to gastric ulceration at the bumper site [7] . Therefore, avoiding external tube traction must be highlighted to the caregivers. For example, avoidance of the placement of gauze pads beneath the external bumper in essential. It has been suggested that amendment of the physical properties of the bumper due to gastric acid exposure can increase pressure necrosis of the gastric wall and results in migration of the bumper [8] . Also, malnutrition, poor wound healing and significant weight gain secondary to successful enteral nutrition all have been implicated in the incidence of BBS [9] . Caregivers should be instructed to push in the PEG approximately one centimeter and to rotate it before Fig. 2: Showing normal saline coming out of the gastrostomy opening indicating that the tube is patent
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