Early Recognition and Diagnosis of Buried Bumper Syndrome: A Report of Three Cases

Abstract

Buried bumper syndrome (BBS) was described as a complication of percutaneous endoscopic gastrostomy (PEG) that occurs when the internal stump of the probe migrates and is located between the gastric wall and the skin. The increase of compression between the internal stump and the external stump of the gastrostomy tube causes pain and the inability to feed. We present the cases of three patients with BBS managed by the metabolic and nutritional support department. These cases intend to illustrate one of the less frequent complications of PEG, clinical presentation, risk factors, diagnosis, and especially clinical management. Although there are no defined gold standards for its management, the most important points in the management of this condition are early recognition, recommendations to avoid ischemic process at the moment of the insertion of the tube, specific care of the gastrostomy tube, and a periodic nutrition evaluation to avoid overweight, which causes traction and excessive pressure in the gastric wall. It is important for physicians to be aware of the recommendations to prevent BBS and its complications, especially in patients in whom communication can be difficult secondary to their pathologies and comorbidities.

An Early Presentation of Buried Bumper Syndrome

“…BBS is described as when the internal stump of the probe migrates and is located anywhere between the gastric wall and the skin [ 3 ]. It usually develops as a consequence of the tight positioning of the external bumper of the PEG tube against the abdominal wall [ 5 ]. This can also occur when the PEG tube is strongly pulled away from the person, moving the internal bumper into the gastrostomy tract [ 5 ].…”

“…It usually develops as a consequence of the tight positioning of the external bumper of the PEG tube against the abdominal wall [ 5 ]. This can also occur when the PEG tube is strongly pulled away from the person, moving the internal bumper into the gastrostomy tract [ 5 ]. Other etiologies occur when there is an increase in hydrochloric acid, which produces physical alterations in the internal bumper, when the patient is obese or has a chronic cough, as well as inadequate gastrostomy tube material or size [ 5 ].…”

“…This can also occur when the PEG tube is strongly pulled away from the person, moving the internal bumper into the gastrostomy tract [ 5 ]. Other etiologies occur when there is an increase in hydrochloric acid, which produces physical alterations in the internal bumper, when the patient is obese or has a chronic cough, as well as inadequate gastrostomy tube material or size [ 5 ]. It has an incidence of 0.3%-2.4%, and the classic sign of BBS is the inability to advance the PEG tube further [ 5 , 9 , 10 ].…”

“…Complication rates vary and are divided into minor and major complications, and many classify it as early or late [ 1 ]. Minor/early complications are three times more likely to happen and include wound infection, bleeding risk within and around the peritoneal area, abdominal organ perforation, tumor seeding, stomal infection, and possible aspiration during the procedure [ 5 ]. As for major/late complications, they mainly include necrotizing fasciitis, gastro-cutaneous fistulas, and buried bumper syndrome (BBS), with or without peritonitis [ 1 , 5 ].…”

“…Minor/early complications are three times more likely to happen and include wound infection, bleeding risk within and around the peritoneal area, abdominal organ perforation, tumor seeding, stomal infection, and possible aspiration during the procedure [ 5 ]. As for major/late complications, they mainly include necrotizing fasciitis, gastro-cutaneous fistulas, and buried bumper syndrome (BBS), with or without peritonitis [ 1 , 5 ]. BBS is a rare complication of PEG tube placement and is defined when the inner bumper migrates through the gastric wall and is lodged between the gastric wall and skin [ 3 ].…”