Acute Buried Bumper Syndrome: A Case Report

Abstract

Case Description: An 18-year-old man with no pertinent medical history was admitted to an acute inpatient rehabilitation unit following a motor vehicle collision which resulted in multiple fractures and a severe traumatic brain injury. Due to dysphagia and variable level of alertness, a PEG tube was placed which the patient tolerated for more than a month. However while on the rehabilitation unit, he noted progressively worsening pain just lateral to his PEG site. There was no history of traction on the PEG tube. Setting: Tertiary care rehabilitation hospital. Results or Clinical Course: The pain continued to worsen and the patient subsequently underwent CT of the abdomen which showed that the internal portion of the PEG was embedded in the anterior abdominal wall. Surgery was consulted and the patient underwent urgent PEG removal. After removal, the patient had immediate relief of his pain and did not have any further issues. Discussion: Percutaneous endoscopic gastrostomy tubes have been used for decades to provide nutrition to patients that are unable to tolerate oral nutrition. The complication rate can be high, reportedly from 16-78% of cases. While the majority of complications are minor, major complications do occur. Buried bumper syndrome occurs in approximately 0.3-2% of patients and is a potentially fatal complication. The internal bumper of the PEG causes ischemic necrosis and can erode through the stomach mucosa to become embedded in the abdominal wall. This typically occurs when the PEG is secured too tightly against the stomach wall, however the definite etiology varies. Once diagnosed, the PEG tube should be urgently removed as necrotizing fasciitis, peritonitis and sepsis can rapidly occur. Conclusion: Many patients are admitted to the rehabilitation unit after having undergone PEG tube placement. As a result, physiatrists should be aware of possible PEG complications. Although uncommon, buried bumper syndrome is a potentially fatal complication and physiatrists should have a high suspicion for this in any patient with abdominal pain after PEG placement.