Case report
Open Access
A Rare but Fatal Complication of PEG: Buried
Bumper Syndrome (BBS)
Kyawzaw Lin1, Jad Sargi2, Aung Naing Lin1, La Min Phyu3 and Khin Myint4
1Internal Medicine Department, The Brooklyn Hospital Center, Affiliate of the Mount Sinai Hospital, 121, Dekalb
Avenue, Brooklyn, NY 11201, USA
2Critical Care Fellow, The Brooklyn Hospital Center, Affiliate of the Mount Sinai Hospital, 121, Dekalb Avenue, Brooklyn, NY 11201, USA
3University of Medicine (1), Yangon, Myanmar
4Attending Physician, Internal Medicine Department, The Brooklyn Hospital Center, Affiliate of the Mount Sinai Hospital, 121, Dekalb Avenue, Brooklyn, NY 11201, USA
2Critical Care Fellow, The Brooklyn Hospital Center, Affiliate of the Mount Sinai Hospital, 121, Dekalb Avenue, Brooklyn, NY 11201, USA
3University of Medicine (1), Yangon, Myanmar
4Attending Physician, Internal Medicine Department, The Brooklyn Hospital Center, Affiliate of the Mount Sinai Hospital, 121, Dekalb Avenue, Brooklyn, NY 11201, USA
*Corresponding author: Kyawzaw Lin, Department of Medicine, The Brooklyn Hospital Center, 1733 West 1st Street, Brooklyn, NY 11223, USA, Tel: 315-664-1916; E-mail:
@
Received: July 03, 2018; Accepted: July 23, 2018; Published: July 25, 2018
Citation: Kyawzaw L, Aung Naing L, Sargi J, Phyu LM, Myint K (2018) A Rare but Fatal Complication of PEG: Buried Bumper Syndrome (BBS). Gastroenterol Pancreatol Liver Disord 6(3): 1-3. DOI: 10.15226/2374-815X/6/3/001130
Abstract
Percutaneous endoscopic gastrostomy(PEG) are used for long
-term enteral feeding. Buried bumper syndrome (BBS) is one of the
rare but life- threatening complications of PEG placement. BBS is
defined as migration of inner bumper (fixating internal part of PEG)
along the stoma channel from the bumper partially covered by overgrowth
mucosa to complete dislodgement of bumper outside the
gastric wall. Here, we present a 72- year- old nursing home resident
with complete BBS.
Introduction
Buried Bumper Syndrome (BBS) is defined as migration of
inner bumper (fixating internal part of PEG) along the stoma
channel. The bumper may be partially covered by over-growth
mucosa or completely dislodged outside the gastric wall.
Complete BBS without visible part of inner pumper can be a
challenge for endoscopic management. Here, we present a 72-
year- old nursing home resident with complete BBS.
A 72-year-old- nursing home male resident was sent from nursing home for a dislodged PEG tube. Past medical history was pertinent for type 2 diabetic mellitus, hypertension, stroke with left sided hemiparesis and dementia. PEG was placed in setting of advanced dementia and dysphagia from CVA 6 months ago. Vitals were stable. Labs were within normal references. On local examination, stoma showed signs of infection. The external pumper was more than 1 cm from the stoma and internal bumper was juxtaposed to the skin under the stoma cavity. Flushing of the PEG tube with normal saline elicited painful withdrawal of hands. CT abdomen showed the internal bumper of the PEG tube was located between the abdominal wall and anterior wall of the stomach compatible with buried bumper syndrome (Figure-2). Inner bumper was removed. Under appropriate antibiotics, another PEG reposition was performed without complication (Figure-3). The patient tolerated tube feeds and was disposed to nursing home.
BBS can be presented with a symptomatic clinical triadinability to insert food or liquids, loss of patency and peristomal leak. In our case, the patient was successfully managed with PEG tube reposition through guided wire via the original track without complications.
Key words: Buried Bumper Syndrome; PEG (Percutaneous Endoscopic Gastrostomy); Gastroenterology;
A 72-year-old- nursing home male resident was sent from nursing home for a dislodged PEG tube. Past medical history was pertinent for type 2 diabetic mellitus, hypertension, stroke with left sided hemiparesis and dementia. PEG was placed in setting of advanced dementia and dysphagia from CVA 6 months ago. Vitals were stable. Labs were within normal references. On local examination, stoma showed signs of infection. The external pumper was more than 1 cm from the stoma and internal bumper was juxtaposed to the skin under the stoma cavity. Flushing of the PEG tube with normal saline elicited painful withdrawal of hands. CT abdomen showed the internal bumper of the PEG tube was located between the abdominal wall and anterior wall of the stomach compatible with buried bumper syndrome (Figure-2). Inner bumper was removed. Under appropriate antibiotics, another PEG reposition was performed without complication (Figure-3). The patient tolerated tube feeds and was disposed to nursing home.
BBS can be presented with a symptomatic clinical triadinability to insert food or liquids, loss of patency and peristomal leak. In our case, the patient was successfully managed with PEG tube reposition through guided wire via the original track without complications.
Key words: Buried Bumper Syndrome; PEG (Percutaneous Endoscopic Gastrostomy); Gastroenterology;
Case Presentation
A 72-year-old- nursing home male resident with past medical
history of Type 2 diabetic mellitus, hypertension, stroke with
left sided hemiparesis and dementia was sent from nursing
home for a dislodged PEG tube. PEG was placed for advanced
dementia and dysphagia due to stroke 6 months ago. Vitals were
stable. Complete blood count, comprehensive metabolic panel
and coagulation panel were within normal references. On local
examination, stoma showed signs of infection. The external
pumper was more than 1 cm from the stoma and internal bumper
was juxtaposed to the skin under the stoma cavity. Flushing of the
PEG tube with normal saline elicited painful withdrawal of hands.
XR (Abdomen) showed moderate constipation with multiple
prominent bowel loops (Figure-1). CT (abdomen) showed internal
bump of the peg tube appears to be between the abdominal wall
and anterior wall of the stomach compatible with buried bumper
syndrome (Figure-2). There is large right renal cysts. Copious
fecal matter suggestive of constipation.Degenerative changes
of the visualized thoracolumbar spine with fusion at L 1-2 as
well as old fracture of L2. Pre-operative bedside examination
showed both the internal/external bumpers were intact. BBS was
removed. Under appropriate pre-operative antibiotics, another
PEG reposition was performed without complication (Figure-3).
The patient tolerated tube feeds the next day and was disposed
to Nursing home.
Figure 1: XR (Abdomen) showed moderate constipation with multiple
prominent bowel loops
Figure 2: CT abdomen showed the internal bumper of the PEG tube was
located between the abdominal wall and anterior wall of the stomach
compatible with buried bumper syndrome.
Figure 3: New percutaneous endoscopic gastrostomy (PEG).
Discussion
Percutaneous endoscopic gastrostomy (PEG) is performed
for long term enteral feeding indicated for neurological and
neurodegenerative disorders that result in impaired swallowing.
With the up-trending requirement for PEG, the increasing
numbers of buried pumper syndrome are reported in the
literature. BBS is usually early complications of PEG (within 30
days of PEG placement) but can be found as late complications
(months to years after the procedure). The incidence is reported
in 0.3-2.4% of PEG. The risk factors for BBS include severe protein
energy malnutrition, prolonged steroid uses, patients with
underlying malignancy or patients undergoing chemoradiation
therapy [1].
The complications of BBS include gastrointestinal bleeding, perforation, peritonitis, and sepsis with or without septic shock from intraabdominal wall abscess. BBS can be presented with a symptomatic clinical triad- inability to insert food or liquids, loss of patency and peristomal leak [1, 2]. Severity of BBS is categorized according to depth of invasion in endoscopy and imaging [3].
Incomplete BBS is defined as BBS with visible parts of inner bumper and does not usually create a serious problem. It can be managed with extraction with the foreign body grasping forceps in most cases. However, in case of deeply ingrown pumper, endoscopic push techniques (using Savary Bougie or biopsy forceps), papillotome-based techniques or pull-techniques (Foreign-body grasping forceps) [4, 5].
Complete BBS is defined when the inner bumper cannot be visible. In complete BBS, CT scan or endoscopic ultrasound can be used to visualize the anatomy of bumper such as depth of invasion and extra-gastric or intramural localization. Extragastric pumpers are usually managed surgically. For internal bumper localized in the gastric wall, endoscopic treatment such as endoscopic push or pull techniques or papillotome-based techniques are done by experienced interventionists [6].
Different approaches have been reported in the literatures for early BBS. It includes to leave or not to leave buried bumper. Some suggested repositioning of the buried bumper into the gastric lumen. Others recommend extraction of buried bumper and placement of a new PEG tube through the same or adjacent tract with the following techniques: (1) via the guidewire to the gastric lumen with endoscope, reposition can be done using a bougie or a hydrostatic balloon dilator; (2) using a gasper under the guidance of endoscope; (3) through radial incision made over the bumper using a wire guided papillotome after guidewire recannulation of gastric wall [7,8,9]; (4) via star like radial incisions of gastric wall using a needle -knife; (5) reposition with a thin gastroscope through PEG tube using rotational movements under direct vision [10]; (6) external removal of bumper through radial incisions in anterior abdomen wall [11] and (7) under fluoroscopic assistance, reposition of the bumper with stiff guidewire or bougie. However, in complicated cases with sepsis, peritonitis or fistulas, laparotomy and surgical removal of buried bumper is a must.
The complications of BBS include gastrointestinal bleeding, perforation, peritonitis, and sepsis with or without septic shock from intraabdominal wall abscess. BBS can be presented with a symptomatic clinical triad- inability to insert food or liquids, loss of patency and peristomal leak [1, 2]. Severity of BBS is categorized according to depth of invasion in endoscopy and imaging [3].
Incomplete BBS is defined as BBS with visible parts of inner bumper and does not usually create a serious problem. It can be managed with extraction with the foreign body grasping forceps in most cases. However, in case of deeply ingrown pumper, endoscopic push techniques (using Savary Bougie or biopsy forceps), papillotome-based techniques or pull-techniques (Foreign-body grasping forceps) [4, 5].
Complete BBS is defined when the inner bumper cannot be visible. In complete BBS, CT scan or endoscopic ultrasound can be used to visualize the anatomy of bumper such as depth of invasion and extra-gastric or intramural localization. Extragastric pumpers are usually managed surgically. For internal bumper localized in the gastric wall, endoscopic treatment such as endoscopic push or pull techniques or papillotome-based techniques are done by experienced interventionists [6].
Different approaches have been reported in the literatures for early BBS. It includes to leave or not to leave buried bumper. Some suggested repositioning of the buried bumper into the gastric lumen. Others recommend extraction of buried bumper and placement of a new PEG tube through the same or adjacent tract with the following techniques: (1) via the guidewire to the gastric lumen with endoscope, reposition can be done using a bougie or a hydrostatic balloon dilator; (2) using a gasper under the guidance of endoscope; (3) through radial incision made over the bumper using a wire guided papillotome after guidewire recannulation of gastric wall [7,8,9]; (4) via star like radial incisions of gastric wall using a needle -knife; (5) reposition with a thin gastroscope through PEG tube using rotational movements under direct vision [10]; (6) external removal of bumper through radial incisions in anterior abdomen wall [11] and (7) under fluoroscopic assistance, reposition of the bumper with stiff guidewire or bougie. However, in complicated cases with sepsis, peritonitis or fistulas, laparotomy and surgical removal of buried bumper is a must.
Conclusion
BBS can lead to complications such as gastrointestinal
bleeding, perforation, peritonitis, sepsis and/or septic shock
from intra-abdominal wall abscess. In our case, the patient was
successfully managed with PEG tube reposition via guided wire
through the original track without complications.
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