(Kiosk 3) Buried Bumper Syndrome in a Severe Acquired Brain Injury Patient: A Case Report of a Late Complication Following Percutaneous Endoscopic Gastrostomy Tube Placement

Case Diagnosis: Buried Bumper Syndrome

Case Description or Program Description: A 40-year-old female presented with a right subcortical intraparenchymal hemorrhage requiring decompressive hemicraniectomy. Immediate complications included respiratory failure necessitating tracheostomy and dysphagia requiring percutaneous endoscopic gastrostomy (PEG) tube placement.

She was subsequently admitted to an inpatient rehabilitation facility (IRF). 35 days following PEG placement, she endorsed abdominal pain, with PEG site tenderness. Nursing staff reported intermittent difficulty with PEG tube flushing. Computed tomography (CT) abdomen revealed the PEG tube’s internal silicon bumper lodged within the abdominal wall musculature, consistent with Buried Bumper Syndrome (BBS).

Setting: Tertiary Rehabilitation Hospital

Assessment/Results: PEG tube was removed and replaced with image guidance. The patient remains at inpatient rehabilitation, with a functional replacement PEG tube and no observed infectious complications.

Discussion (relevance): BBS is a rare, potentially life-threatening complication of PEG tube placement. Reportedly occurring in < 2.5% of placements, BBS happens when erosion of the gastric wall results in migration of the internal bumper between the gastric wall and the skin. BBS is often a late complication, occurring months to years after placement, but has been identified as early as 8 days. In IRFs, patients often present with site tenderness and difficulty flushing the PEG, as in this patient, though most publications describe gastric leakage or erythema. Risk factors include obesity and excessive tension on the internal balloon, usually from tightening of the external bolster. BBS is confirmed endoscopically or by CT. Untreated, BBS can progress to sepsis from necrosis/perforation of the gastric wall, peritonitis, or subcutaneous tissue infection.
Preventive interventions for BBS may include extending the external tube, daily checks for excessive bolster tightness and appropriately timed removal of retention sutures in applicable PEG tubes.

Conclusions: BBS requires urgent identification and intervention. Interdisciplinary communication and site monitoring allows for detection of BBS and potential prevention. When BBS is suspected, imaging and PEG tube removal is indicated.