Age and Ageing 2005 34(6):650-651; doi:10.1093/ageing/afi204
© The Author 2005. Published by Oxford University Press on behalf of the British Geriatrics Society. All rights reserved. For Permissions, please email: journals.permissions@oxfordjournals.org
Buried Bumper Syndrome complicated by intra-abdominal sepsis
Gareth Walters,
P. Ramesh and
Muhammed Ibrahim Memon
Department of Care of the Elderly, Solihull Hospital, Heart of England Foundation Trust, Lode Lane, Solihull, West Midlands B91 2JL, UK
Address correspondence to P. Ramesh. Fax (+44) 0121 424 4611. Email: parthasarathy.ramesh{at}heartofengland.nhs.uk
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Abstract
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There is growing evidence that enteral feeding tubes are associated
with increased mortality and complication rates in patients
with advanced dementia. Buried Bumper Syndrome is an uncommon,
but well documented late complication of PEG placement. Our
case report reinforces this recognised risk of PEG feeding in
an elderly, cognitively impaired patient.
Keywords: percutaneous endoscopic gastrostomy, dementia, buried bumper syndrome
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Introduction
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Percutaneous Endoscopic Gastrostomy (PEG) is used increasingly
for long-term enteral support in patients with dementia. However,
numerous complications have been reported since its introduction
in 1980 [
1]. Buried Bumper Syndrome (BBS) is an uncommon, but
well documented complication of PEG placement. We report a case
of BBS complicated by a large intra-abdominal abscess.
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Case report
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An 81-year-old lady with advanced dementia was admitted to our
hospital from a nursing home with vomiting and rigors. A PEG
had been
in situ for 3 years. Examination revealed a large,
tender, right-sided abdominal mass. She was tachycardic and
pyrexial with raised inflammatory markers. Ultrasound abdomen
revealed a large intra-peritoneal abscess. Cultures grew enterococcal
species and she was commenced on intravenous antibiotics. Gastroscopy
and CT abdomen revealed migration of the PEG internal bumper
out of the stomach. The patient was referred to the surgeons
for urgent exploration and removal of PEG. She died two days
after the procedure following a brainstem infarction.
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Discussion
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BBS is a serious complication of PEG tube insertion first described
in 1988 [
2,
3] and reported to occur in 0.3–2.4% of patients
[
4]. It is a late complication occurring up to 3 years post
PEG insertion [
5], but has been described at 21 days [
6]. The
internal bumper becomes lodged along the gastrostomy tract between
the gastric wall and skin. Epithelialisation occurs and the
bumper becomes covered with gastric mucosa. Diagnosis should
be considered if abdominal pain, peri-tubular leakage, or inability
to infuse feed occur. This can be confirmed endoscopically with
the help of CT or contrast studies. Failure to recognise the
syndrome has resulted in gastric perforation and gastrointestinal
haemorrhage [
6].
PEG feeding is commonly used to provide nutrition in demented patients. There is no evidence that this provides any improvement in nutritional state, functional capacity or survival and is actually a risk factor for developing aspiration [7]. Additionally, the quality of life of a patient with a PEG tube can be adversely affected once the tube is inserted [8]. This case report reinforces the risks of PEG feeding in advanced dementia.
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References
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- Gauderer MWl, Ponsky JL, Izant RJ. Gastrostomy without laparotomy: a percutaneous endoscopic technique. J Paediatric Surg 1980; 15 872–5.
- Shallman RW, Norfleet RG, Hardache JM. Percutaneous endoscopic gastrostomy feeding tube migration and impaction in the abdominal wall. Gastrointest Endosc 1988; 34 367–68.[Medline]
- Gluck M, Levant JA, Drennan F. Retraction of Sacks-Vine gastrostomy tubes into the gastric wall: a report of seven cases. Gastrointest Endosc 1988; 34 215.
- Venu RP, Brown RD. Pastika BJ Erickson LW. The buried bumper syndrome: a simple management approach in two patients. Gastrointest Endosc 2002; 56 582–84.[Medline]
- Ballester P, Ammori BJ. Laparoscopic removal and replacement of tube gastrostomy in the management of buried bumper syndrome. Int J Surg 2004; 5 2.
- Anagnostopoulos GK, Kostopoulos P, Arvanitidis DM. Buried Bumper Syndrome with a fatal outcome, presenting early as gastrointestinal bleeding after percutaneous endoscopic gastrostomy placement. J Postgrad Med 2003; 49 325–27.[Medline]
- Finucane TE, Christmas C, Travis K. Tube feeding in patients with advanced dementia. JAMA 1999; 282 1365–70.[Abstract/Free Full Text]
- Monteleoni C, Clark E. Using rapid cycle quality improvement methodology to reduce feeding tubes in patents with advanced dementia. BMJ 2004; 329 491–94.[Abstract/Free Full Text]
Received July 28, 2005; accepted in revised form August 3, 2005.
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Abstract
Introduction