Humaira Hashmi, MD

A 22-month-old boy with failure to thrive presented with a 3-day history of rhinorrhea, fever, and abdominal pain associated with tube feeding. A percutaneous endoscopic gastrostomy (PEG) tube had been placed 2 months before this visit. Physical examination found tenderness on palpation around the PEG tube and a yellow discharge from the site. Culture of the discharge grew methicillin-sensitive 

. A blood culture was negative and fluoroscopy with contrast of the PEG tube was normal. The child was treated with antibiotic agents for a localized infection of the PEG tube site. After 7 days, however, symptoms failed to resolve.

  Abdominal CT shows internal bumper of the PEG tube within the abdominal wall (arrows).   


 Follow-up examination found a palpable, erythematous mass at the PEG tube site, presumed to be an abscess. A subsequent ultrasound study, however, was negative for abscess or fluid collection. Fluoroscopy with contrast found normal flow into the stomach. A CT scan of the abdomen showed that the internal bumper of the PEG tube had migrated and lodged between the abdominal wall and the skin (

), a phenomenon called buried bumper syndrome. The bumper was the palpable mass noted above. The PEG tube was removed by external traction and replaced with a Tri-Funnel tube without complications and the local infection resolved.

 Endoscopic view of previous PEG tube site in the gastric mucosa (arrow). 

 
 Buried bumper syndrome is an uncommon but serious complication of a PEG tube. It occurs in 1.6% of children with the device and is generally a late complication, occurring months or even years after the initial tube placement.1 The internal bumper of the tube erodes through the gastric wall and becomes lodged between the wall and the skin along the original tube tract.2 The most likely cause is excessive tension between the internal and external bumpers. The most common presenting symptoms of buried bumper syndrome-abdominal pain, inability to infuse feedings, and leakage around the tube-are associated with clogging and immobilization of the tube.

A buried bumper should always be removed, even if the patient is asymptomatic, to avoid serious complications such as gastrointestinal bleeding, gastric perforation, and peritonitis.3  As this case illustrates, infusion of feeds may be unobstructed despite BBS. Also of note in this case, findings from ultrasound and fluoroscopic dye studies were negative. Abdominal CT may be required to identify the relocated bumper.

 
   •	Clinicians should have a high index of suspicion for BBS in a child with a PEG tube who presents with feeding intolerance.
    • High suspicion for BBS should remain if feeding intolerance persists despite normal findings on ultrasound and fluoroscopy with contrast.  
    •	BBS typically is a late complication, and should be considered even several years after PEG tube placement.

  1. Khalil Q, Kibria R, Akram S. Acute buried bumper syndrome. 

2. Schrag SP, Sharma R, Jaik NP, et al. Complications related to percutaneous endoscopic gastrostomy (PEG) tubes. A comprehensive clinical review. 

  3.Â  Schapiro GD, Edmundowicz SA. Complications of percutaneous endoscopic gastrostomy. 

Articles

  A 22-month-old boy with failure to thrive presented with a 3-day history of rhinorrhea, fever, and abdominal pain associated with tube feeding. A PEG tube had been placed 2 months before this visit.   

A Toddler Intolerant of Tube Feeding


Figure 1.  Abdominal CT shows internal bumper of the PEG tube within the abdominal wall (arrows).

Follow-up examination found a palpable, erythematous mass at the PEG tube site, presumed to be an abscess. A subsequent ultrasound study, however, was negative for abscess or fluid collection. Fluoroscopy with contrast found normal flow into the stomach. A CT scan of the abdomen showed that the internal bumper of the PEG tube had migrated and lodged between the abdominal wall and the skin (

Buried bumper syndrome is an uncommon but serious complication of a PEG tube. It occurs in 1.6% of children with the device and is generally a late complication, occurring months or even years after the initial tube placement.

 The internal bumper of the tube erodes through the gastric wall and becomes lodged between the wall and the skin along the original tube tract.

The most likely cause is excessive tension between the internal and external bumpers. The most common presenting symptoms of buried bumper syndrome-abdominal pain, inability to infuse feedings, and leakage around the tube-are associated with clogging and immobilization of the tube.

A buried bumper should always be removed, even if the patient is asymptomatic, to avoid serious complications such as gastrointestinal bleeding, gastric perforation, and peritonitis.

  As this case illustrates, infusion of feeds may be unobstructed despite BBS. Also of note in this case, findings from ultrasound and fluoroscopic dye studies were negative. Abdominal CT may be required to identify the relocated bumper.

•	Clinicians should have a high index of suspicion for BBS in a child with a PEG tube who presents with feeding intolerance.
 •	High suspicion for BBS should remain if feeding intolerance persists despite normal findings on ultrasound and fluoroscopy with contrast. 
 •	BBS typically is a late complication, and should be considered even several years after PEG tube placement.


1. Khalil Q, Kibria R, Akram S. Acute buried bumper syndrome. 

. 2010;103:1256-1258. 
2. Schrag SP, Sharma R, Jaik NP, et al. Complications related to percutaneous endoscopic gastrostomy (PEG) tubes. A comprehensive clinical review. 

. 2007;16:407-418.
 3. Schapiro GD, Edmundowicz SA. Complications of percutaneous endoscopic gastrostomy. 

A 22-month-old boy with failure to thrive presented with a 3-day history of rhinorrhea, fever, and abdominal pain associated with tube feeding. A PEG tube had been placed 2 months before this visit.

Buried Bumper Syndrome in a Toddler

For 3 days, a 7-year-old girl had severe, generalized abdominal pain. The patient described the pain as sharp and achy without radiation; she denied any relieving or aggravating factors. She also reported decreased appetite and energy for the past week.

Vital signs were normal. An initial complete blood cell (CBC) count showed a white blood cell count of 18,000/μL, with 20% bands. Results of a chemistry panel were normal. Stool was positive for occult blood. A CT scan showed marked gastric wall thickening measuring 18 mm (

). The patient was admitted to the hospital. Results of another CBC count with differential and a second chemistry panel as well as a hepatic panel were normal. Stool was still positive. Her IgA level was 542 mg/dL (normal range, 100 to 200 mg/dL). Results of an upper endoscopy with biopsy were normal, without pathology. Five days after admission, the patient's ankles and knees became swollen. The next day, purpuric lesions developed on her feet and legs (

). A dermatologist who examined the patient diagnosed Henoch-Schönlein purpura (HSP). Although the parents refused a skin biopsy, the child's clinical presentation, elevated IgA level, and rash all pointed to this diagnosis.

The presentation of HSP varies with each patient. Clinical manifestations of this IgA-mediated vasculitis primarily include palpable purpura, arthralgia, arthritis, abdominal pain, GI bleeding, and nephritis. Abdominal pain with concomitant hematochezia affects more than half of patients with HSP and may be the presenting complaint. The abdominal pain is often sharp and colicky and results from submucosal and subserosal hemorrhage and edema, with thrombosis of the microvasculature in the gut. Gastric wall thickening has not been reported as a manifestation of HSP. This finding may be an early clue to the diagnosis of HSP in children with abdominal pain who present without the characteristic purpuric lesions.

The child completed a 10-day course of oral prednisone. After 1 month, a follow-up CT scan showed significantly reduced gastric wall thickening. The patient is currently asymptomatic.

Humaira Hashmi, MD

Articles

A Toddler Intolerant of Tube Feeding

Buried Bumper Syndrome in a Toddler

Henoch-Schönlein purpura with gastric wall thickening