Buried bumper syndrome

PEG tubes are becoming increasingly in demand for alternative enteral feeding options. Thus, BBS is a common complication that one should be aware of and how to manage it. Hope this helps..

1. Management of Buried Bumper
Syndrome
By Dr Kalsom Abdulah
28.5.2014

2. 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.

3. PEG tube placement

4. 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

5. 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

6. 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

7. 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

8. Complications of BBS

Perforation of stomach

Peritonitis

Death

9. 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

10. 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

11. 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