Buried bumper syndrome causing rectus abdominis necrosis in a man with tetraplegia

Early Recognition and Diagnosis of Buried Bumper Syndrome: A Report of Three Cases

Buried bumper syndrome (BBS) was described as a complication of percutaneous endoscopic gastrostomy (PEG) that occurs when the internal stump of the probe migrates and is located between the gastric wall and the skin. The increase of compression between the internal stump and the external stump of the gastrostomy tube causes pain and the inability to feed. We present the cases of three patients with BBS managed by the metabolic and nutritional support department. These cases intend to illustrate one of the less frequent complications of PEG, clinical presentation, risk factors, diagnosis, and especially clinical management. Although there are no defined gold standards for its management, the most important points in the management of this condition are early recognition, recommendations to avoid ischemic process at the moment of the insertion of the tube, specific care of the gastrostomy tube, and a periodic nutrition evaluation to avoid overweight, which causes traction and excessive pressure in the gastric wall. It is important for physicians to be aware of the recommendations to prevent BBS and its complications, especially in patients in whom communication can be difficult secondary to their pathologies and comorbidities.

Buried bumper syndrome: A complication of percutaneous endoscopic gastrostomy

Percutaneous endoscopic gastrostomy (PEG) is a widely used method of nutrition delivery for patients with long-term insufficiency of oral intake. The PEG complication rate varies from 0.4% to 22.5% of cases, with minor complications being three times more frequent. Buried bumper syndrome (BBS) is a severe complication of this method, in which the internal fixation device migrates alongside the tract of the stoma outside the stomach. Excessive compression of tissue between the external and internal fixation device of the gastrostomy tube is considered the main etiological factor leading to BBS. Incidence of BBS is estimated at around 1% (0.3%-2.4%). Inability to insert, loss of patency and leakage around the PEG tube are considered to be a typical symptomatic triad. Gastroscopy is indicated in all cases in which BBS is suspected. The depth of disc migration in relation to the lamina muscularis propria of the stomach is critical for further therapy and can be estimated by endoscopic or transabdominal ultrasound. BBS can be complicated by gastrointestinal bleeding, perforation, peritonitis, intra-abdominal and abdominal wall abscesses, or phlegmon, and these complications can lead to fatal outcomes. The most important preventive measure is adequate positioning of the external bolster. A conservative approach should be applied only in patients with high operative risk and dismal prognosis. Choice of the method of release is based on the type of the PEG set and depth of disc migration. A disc retained inside the stomach and completely covered by the overgrowing tissue can be released using some type of endoscopic dissection technique (needle knife, argon plasma coagulation, or papillotome through the cannula). Proper patient selection and dissection of the overgrowing tissue are the major determinants for successful endoscopic therapy. A disc localized out of the stomach (lamina muscularis propria) should be treated by a surgeon.

Pain without nociception?

We describe a young woman with complete cervical spinal cord transsection, who developed significant abdominal pain, triggered by gastric distension and deep abdominal palpation. On the basis of the nature of her spinal cord injury, her brain-gut axis was limited to vagal pathways. Studies in mammalian models of human visceral sensation consistently showed that the subdiaphragmatic vagus contains a homogeneous population of afferents that are activated by low-intensity stimuli, which are generally believed to be important in regulating autonomic function and perhaps contributing to visceral sensory experiences triggered by such low-intensity stimuli (e.g. fullness, nausea), but not pain, although many fibers encode stimuli well into the noxious range. In contrast, spinal afferent pathways include fibers with high-activation thresholds that are thought to represent specialized nociceptors. This illustrative case argues against an exclusive role of specialized nociceptive pathways in visceral pain, but supports a concept of intensity coding with the composite of vagal and spinal input contributing to conscious perception and pain.