Buried Bumper Syndrome Revisited: A Rare but Potentially Fatal Complication of PEG Tube Placement

Percutaneous endoscopic gastrostomy (PEG) has been used for providing enteral access to patients who require long-term enteral nutrition for years. Although generally considered safe, PEG tube placement can be associated with many immediate and delayed complications. Buried bumper syndrome (BBS) is one of the uncommon and late complications of percutaneous endoscopic gastrostomy (PEG) placement. It occurs when the internal bumper of the PEG tube erodes into the gastric wall and lodges itself between the gastric wall and skin. This can lead to a variety of additional complications such as wound infection, peritonitis, and necrotizing fasciitis. We present here a case of buried bumper syndrome which caused extensive necrosis of the anterior abdominal wall. 1. Introduction 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 [1]. 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 [2]. 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]. We present here a case of BBS followed by a discussion of its etiology, management, and prevention. 2. Case description A 70-year-old female with multiple comorbidities presented to the ER from the nursing home with symptoms suggestive of septic shock. At the time of admission, the patient was undergoing active treatment for urinary tract infection in the nursing home. Physical examination of the patient revealed respiratory distress and hypotension, so emergency intubation was done and vasopressors started to maintain blood pressure. Empiric broad spectrum antibiotics were initiated for septic shock. Patient was then transferred to the medical intensive care unit for further management. Patient history revealed that the PEG tube was inserted one year prior due to dysphagia from a stroke. Upon abdominal examination, the PEG tube was in place in the epigastric area with signs of edema and erythema on the right lateral side of the