Buried Bumper Syndrome (BBS) is a complication that can occur following the placement of a percutaneous endoscopic gastrostomy (PEG) tube, used for long-term nutritional support. This syndrome involves the internal retention disc, often called the “bumper,” migrating from its correct position inside the stomach. The bumper erodes into the gastric wall and surrounding tissues, leading to a loss of the tube’s intended function. The incidence of this complication is generally low, affecting an estimated 0.3% to 4% of patients with a PEG tube.
The Mechanism of Bumper Migration
The underlying cause of Buried Bumper Syndrome is excessive pressure exerted on the tissue between the internal bumper and the external bolster of the PEG tube. When the external device is tightened too much against the abdominal wall, it creates continuous tension on the gastrocutaneous tract. This sustained pressure compromises the blood flow to the gastric wall, leading to a condition known as pressure necrosis.
As the tissue at the tube’s insertion site begins to break down, the internal bumper slowly erodes into the stomach wall. This erosion allows the internal bumper to migrate out of the stomach lumen and become lodged within tissue layers, such as the gastric wall or subcutaneous tissue beneath the skin. The gastric mucosa may then grow over the migrating bumper, effectively burying it and isolating it from the stomach cavity.
The process of migration is often gradual, though it can occur as early as one week after tube placement, it is typically considered a late complication. Once the bumper is trapped within the tissue, the gastrostomy tract can collapse or become partially obstructed.
Identifying Symptoms and Confirming Diagnosis
The clinical presentation of Buried Bumper Syndrome often involves signs and symptoms that indicate tube malfunction. Patients or caregivers may notice increased leakage of gastric contents or feeding formula around the tube’s insertion site. A common complaint is difficulty or resistance when attempting to administer feeds, fluids, or medications through the tube.
A hallmark sign is the inability to rotate the PEG tube, which may feel “fused” or fixed to the abdominal wall. The tube can also no longer be gently pushed inward toward the stomach, a normal maneuver for PEG tube care. Other local signs include pain at the stoma site, swelling, redness, and hardening of the tissue surrounding the tube.
Diagnosis is often suspected based on these clinical features, but it is confirmed using imaging or endoscopic procedures. Upper endoscopy is considered the most definitive method, allowing a direct view of the bumper’s position. Imaging techniques such as abdominal ultrasound or computed tomography (CT) scans can visualize the migrated bumper’s location within the abdominal wall.
Management and Treatment Options
Treatment for Buried Bumper Syndrome is determined by the depth of the bumper’s migration and the patient’s overall clinical status. In cases where the bumper is only partially embedded, non-surgical endoscopic removal techniques are often attempted first. These minimally invasive procedures are performed with a flexible endoscope and may involve simple external traction if the tube has a collapsible internal bolster.
For more deeply buried bumpers, specialized endoscopic methods are employed to free the device. Techniques include using a needle knife or a papillotome to incise the tissue that has grown over the bumper, or using traction techniques to pull it back into the stomach lumen. Once the bumper is released, the PEG tube is removed, usually through the mouth, and a new feeding tube is placed, often through the same tract if the site is healthy.
Surgical intervention becomes necessary when the bumper is deeply embedded in the abdominal wall or if endoscopic methods fail. This may involve a laparoscopic or open surgical approach to directly access and remove the buried bumper. If the buried bumper is associated with severe complications like abscess formation or peritonitis, surgical drainage and subsequent tube replacement at a different site may be required.
Strategies for Prevention
Preventing Buried Bumper Syndrome centers on meticulous care and proper management of the PEG tube’s external components. The most important preventive measure is ensuring the external bolster is not overtightened against the skin. Clinicians recommend maintaining a small gap, typically between 0.5 to 1 centimeter, between the external bolster and the abdominal wall to avoid excessive traction and pressure.
Routine daily care should include gently rotating the PEG tube 360 degrees and pushing it in and out one to two centimeters. This movement prevents the internal bumper from continuously pressing on the same area of the stomach lining, which helps to maintain the health of the tissue. Caregivers should also be instructed to avoid placing gauze pads or other absorbent materials directly under the external bolster, as this can inadvertently increase tension.
This includes regularly measuring the length of the external tube segment and promptly reporting any resistance to rotation, leakage, or unexplained pain to a healthcare provider. Proactive monitoring and correct maintenance reduce the risk of the pressure-induced tissue damage that leads to this syndrome.