Delayed Diagnosis of Buried Bumper Syndrome When Only the Jejunostomy Extension is Used in a Percutaneous Endoscopic Gastrostomy-jejunostomy Levodopa-carbidopa Intestinal Gel Delivery System

Abstract

Direct intrajejunal levodopa-carbidopa intestinal gel (LCIG) administered through a percutaneous endoscopic gastrostomy (PEG) with a jejunal extension tube (PEG-J) is an FDA-approved modality for treatment of patients with advanced Parkinson’s disease (PD). Buried bumper syndrome (BBS) is a rare complication associated with PEG tubes inserted for drug administration or enteral feeding. The syndrome is diagnosed endoscopically revealing burial of the internal bumper in the gastric wall, causing numerous serious complications. When only the J extension of a PEG-J is used to deliver medications, and the G tube is not utilized, a delay in the diagnosis of BBS can occur. This is likely as the small caliber J extension tube remains patent and functional. We present the case of an elderly patient with advanced PD on LCIG therapy, who presented with a dislodged J-tube from a PEG-J system. Endoscopy revealed BBS that had likely developed prior to dislodgment of J-extension and despite a conservative approach, the internal bumper needed to be surgically extracted to prevent further complications.

Buried bumper syndrome in percutaneous endoscopic gastrostomy with a jejunal extension tube in patients undergoing levodopa–carbidopa intestinal gel treatment

“…Various treatment methods for BBS in PEG have been introduced [ 8 – 13 ]. Endoscopic treatment is an option, as it is less invasive than surgical intervention [ 9 , 11 ].…”

“…Endoscopic treatment is an option, as it is less invasive than surgical intervention [ 9 , 11 ]. However, complicated or difficult cases should be treated with surgery [ 12 , 13 ]. BBS in PEG-J has several characteristics different from those of BBS in PEG.…”

“…As patients with PD patients undergoing the LCIG therapy can eat orally, they do not require gastric tubes of PEG-J, making PEG-J care less frequent. If a small caliber of the jejunal tube remains patent and functional, a delay in diagnosing BBS can occur until it is noticed incidentally or a symptom appears [ 13 ]. Patients with PD tend to gain weight if LCIG treatment is effective, increasing the width of abdominal wall.…”