Percutaneous Endoscopic Gastrostomy Diagnosis of Buried Bumper Syndrome 1

Percutaneous Endoscopic Gastrostomy Diagnosis of Buried Bumper Syndrome –

Decision Tree

Are symptoms suggestive of buried bumper? (pain and tenderness at PEG site, pain on feeding, tube blockage,

extravasation of feed, site breakdown, peristomal infection)

Seek advice from your local nutrition team

Buried bumper unlikely – consider alternative

explanation for symptoms eg infection

Consider imaging if diagnosis unclear (CT scan, contrast

study, abdominal ultrasound or EUS)4

Gastroscopy4

Consider alternative explanation for symptoms

eg infection4

Yes No

Have you confirmed that this is a PEG tube(not a jejunostomy tube or PEG-J)?

Is it possible to push the PEG tube into the stomach?

Seek advice from your local nutrition teamNo

No

No

Yes

Yes

Yes

Is diagnosis of buried bumper confirmed?

See “Management of buried bumper”

Decision Tree

November 2012

The BAPEN Principles of Good Nutritional Practice (Decision Trees) have been prepared to assist health care professionals in the decision making processes surrounding nutritional care. Users of these materials may only do so on the condition that they exercise their own professional knowledge and skills. BAPEN does not owe a duty of care and cannot accept liability to anyone using these Decision Trees.

Percutaneous Endoscopic Gastrostomy Diagnosis of Buried Bumper Syndrome –

Key Points

1.Definitionofburiedbumper

Buried bumper is the partial or complete growth of gastric mucosa over the internal bumper. The bumper may migrate through the gastric wall and may lodge anywhere along the gastrostomy tract. It usually occurs months to years after PEG placement1, but has been reported as early as 6 days after PEG insertion2.

2.Incidenceofburiedbumper

0.3%–2.4% of patients with a gastrostomy (may be reduced in recent years with improvements in the design of tubes)1,3,4.

3.Riskfactorsforaburiedbumper5,6

Excessive tension between the internal and external bumpers

Failure to adjust the position of the external bumper as the patient’s nutritional state improves

PEG tube characteristics

Small inner bumper

Sharp tapered flange

Stiff (polyurethane) tubes

Silicon internal retention disc

Malnutrition and poor wound healing

4.Diagnosisofburiedbumper

Endoscopy7-9

At endoscopy the appearances of a buried bumper can vary from heaped up mucosa around the inner bumper partly covering it to a heaped mound in which it can be very difficult to see the bumper at all. There may be pus oozing from a pimple in the mound to give a clue, or it may be possible to see fluid appearing from a crevice in the mucosa when the tube is flushed.

Abdominalultrasound7

Endoscopicultrasound10-12

Contrast studies4

CT scan13

Both abdominal ultrasound and CT scans may be used to determine the position of the bumper in the abdominal wall and to visualise any associated abscess. Some authors have suggested that bumpers that are located in an extramural position should be removed surgically11,12.

Completely buried bumper – bumper not visible at all at endoscopy

Developing a buried bumper

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Percutaneous Endoscopic Gastrostomy Diagnosis of Buried Bumper Syndrome –

References

1. Potack JZ, Chokhavatia S. Complications of and Controversies Associated With Percutaneous Endoscopic Gastrostomy: Report of a Case and Literature Review. Medscape J Med. 2008; 10(6): 142. Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2491665/

2. Khalil Q, Kibria R, Akram S. Acute buried bumper syndrome. South Med J 2010; 103(12): 1256-1258. Available from: http://www.medscape.com/viewarticle/733885

3. Baskin WN. Acute complications associated with bedside placement of feeding tubes. Nutrition in Clinical Practice 2006; 21:40-55. Available from: http://ncp.sagepub.com/content/21/1/40.abstract

4. Itkin M, DeLegge MH, Fang JC, McClave SA, Kundu S, d’Othee BJ, et al; Society of Interventional Radiology; American Gastroenterological Association Institute; Canadian Interventional Radiological Association; Cardiovascular and Interventional Radiological Society of Europe. Multidisciplinary practical guidelines for gastrointestinal access for enteral nutrition and decompression from the Society of Interventional Radiology and American Gastroenterological Association (AGA) Institute, with endorsement by Canadian Interventional Radiological Association (CIRA) and Cardiovascular and Interventional Radiological Society of Europe (CIRSE). Gastroenterology. 2011; 141(2):742-65. Available from: http://www.sirweb.org/clinical/cpg/PIIS1051044311008505.pdf

5. McClave SA, Neff RL. Care and Long-Term Maintenance of Percutaneous Endoscopic Gastrostomy Tubes. Journal of Parenteral and Enteral Nutrition. 2006 30:S27-S38. Available from: http://sppen.highwire.org/content/35/1/56.full

6. Westaby D, Young A, O’Toole P, Smith G, Sanders DS. The provision of a percutaneously placed enteral tube feeding service. Gut 2010; 59: 1592-605. Available from: http://www.bsg.org.uk/clinical-guidelines/small-bowel-nutrition/the-provision-of-a-percutaneously-placed-enteral-tube-feeding-service.html

7. Elbaz T, Rejchrt S, Douda T, Cyrany J, Repák R, Bureš J. Buried bumper syndrome: an uncommon complication of percutaneous endoscopic gastrostomy. Report of three cases. Folia Gastroenterol Hepatol 2006; 4 (2): 61 – 66. Available from: http://www.pro-folia.org/files/1/2006/2/el_baz.pdf

8. Atlanta South Gastroenterology. Buried Bumper Syndrome. Atlas of Gastrointestinal Endoscopy. Available from: http://www.endoatlas.com/st_ge_19.html

9. Leung KK, Brenner JW, Dekovich AA. Buried Bumper Syndrome: An Uncommon Complication of Percutaneous Endoscopic Gastrostomy. Visible Human Journal of Endoscopy. Available from: http://www.vhjoe.org/Volume7Issue2/7-2-4.htm

10. Ulla JL, Alvarez V, Fernandez-Salgado E, Vazquez-Astray E. Radial endoscopic ultrasonography and buried bumper endoscopic solution. Surg Laparosc Endosc Percutan Tech 2007; 17(3): 201-202. Available from: http://journals.lww.com/surgical-laparoscopy/Abstract/2007/06000/Radial_Endoscopic_Ultrasonography_and_Buried.12.aspx

11. Tanaka Y, Akahoshi K, Motomura Y, Osoegawa T, Yukaya T, Ihara E, Iwao R, Komori K, Nakama N, Itaba S, Kubokawa M, Hisano T, Nakamura K. Pretherapeutic evaluation of buried bumper syndrome by endoscopic ultrasonography. Endoscopy. 2012 May;44 Suppl 2:E162. Available from: https://www.thieme-connect.de/ejournals/pdf/10.1055/s-0031-1291715.pdf

12. Braden B, Brandstaetter M, Caspary WF, Seifert H. Buried bumper syndrome: treatment guided by catheter probe US. Gastrointest Endosc 2003; 57(6): 747-751. Available from: http://www.giejournal.org/article/S0016-5107(03)00169-X/abstract

13. Schrag PS, Sharma R, Jaik NP etal. Complications related to Percutaneous Endoscopic Gastrostomy Tbues. A comprehensive clinical review. J Gastrointestin Liver Dis 2007; 16: 407-418. Available from: http://www.jgld.ro/2007/4/9.pdf

Further Reading BSG Guideline “The provision of a percutaneously

placed enteral feeding service”. http://www.bsg.org.uk/clinical-guidelines/small-bowel-nutrition/the-provision-of-a-percutaneously-placed-enteral-tube-feeding-service.html

Multidisciplinary Practical Guidelines for Gastrointestinal Access for Enteral Nutrition and Decompression From the Society of Interventional Radiology and American Gastroenterological Association (AGA) Institute, With Endorsement by Canadian Interventional Radiological Association (CIRA) and Cardiovascular and Interventional Radiological Society of Europe (CIRSE). http://www.sirweb.org/clinical/cpg/PIIS1051044311008505.pdf

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