Management of Buried Bumper SyndromeBy Dr Kalsom Abdulah

28.5.2014

Percutaneous Endoscopic Gastrostomy (PEG)

Percutaneous endoscopic gastrostomy (PEG) was first reported in the literature in 1980 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 deficits and swallowing disorders 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. These 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 0.3–2–4% of patients.

PEG tube placement

Indications & contraindications for PEG tube

Indications• Neurological event: CVA, PD, ALS, MS, HIV encephalopathy, trauma, dementia, brain tumour• Anatomic: tracheoesophageal fistula• Malignant obstruction: oropharyngeal or oesophageal masses• Other: gastric decompression, burn patients, severe bowel motility disorder

Relative Contraindications• Peritoneal metastases• Peritoneal dialysis• Ascites• Coagulopathy• Poor life expectancy• Acute illness (respiratory distress)• Severe obesity• Open abdominal wound• Ventral hernia• Portal hypertension with gastric varices• Sepsis

CVA – cerebrovascular accident; PD – Parkinson’s disease;ALS – Amyotrophic Lateral Sclerosis; MS – Multiple Sclerosis

Acute Buried Bumper Syndrome

BBS is uncommon complication of PEG tube placement

Occurs when the internal bumper of a PEG tube erodes and migrates throught the gastric wall and becomes lodged anywhere between the gastric wall and the skin

If not removed and treated appropriately, can lead to life-threatening complications

Incidence rate is 1.5-2.4% and can occur from days to years post PEG placement

Risk factors for BBS

• Obesity

• Rapid weight gain, in particular if loosening of the external bumper is not also attended to

• Patient manipulation and pulling of the PEG

• Placement of multiple gauze pads or other coverings beneath the external bumper

• Repositioning of the external bumper by inexperienced personnel

• Chronic/severe cough

• Frequent or inadvertent tube traction by caregivers

Signs & Symptoms of BBS

Clogging and immobilization of the tube

Abdominal pain

Inability to infuse feedings

Peritubular leakage

Ability to palpate internal bumper clinically

Endoscopic evidence

CT showing migrated internal bumper

Complications of BBS

Perforation of stomach

Peritonitis

Death

Possible Considerations in Preventing Buried Bumper Syndrome

• Allow an additional 1.5–2 cm between the external bumper and the skin.

• Visualize the internal bumper (immediately following the PEG placement) to confirm its location prior to applying the external bumper

• Once a day gently rotate and push the PEG in and out ~1–2 cm

• Display simple diagrams of the PEG system at the bedside in the hospital or clinic.

• Length of the protruding external portion of the PEG should be measured periodically to recognize early migration

Treatment of BBS

Removal of buried bumper (even if asymptomatic)

PEG removal using external traction

Incision & drainage if abdominal wall abscess present

Endoscopy

To determine the exact condition of the site

Whether same site can be used for replacement PEG

Plan the direction of PEG removal

Replacement tube through same site if healed previous abscess

Administer antibiotics

Wound care

Conclusion

BBS is an unusual late complication of percutaneous endoscopic gastrostomy tube placement

Is not a benign problem and can lead to life threatening complications

Treatment usually involves removal of the tube along with wound care

Although several factors can contribute to the development of disorder, can be prevented with proper patient care and education for the caregiver and patient