1522 - Beneath the Surface: Unmasking Buried Bumper Syndrome in a Traumatic Brain Injury Patient

Case Diagnosis: Buried bumper syndrome in a patient with traumatic brain injury

Case Description: A 60 y/o female sustained a traumatic brain injury (TBI) from an unwitnessed fall down the stairs and was admitted to an inpatient rehabilitation facility (IRF) for impairments including cognitive deficits, fluent aphasia, and dysphagia requiring gastrostomy tube (G-tube). About four weeks into the patient’s rehabilitation course, she developed insidious onset, vague abdominal pain after tube feeds, with initial work-up unremarkable. Eventually she had frank bloody output from her G-tube requiring transfer to an acute care hospital for further work-up, where CT Abdomen Pelvis identified G-tube balloon migration into the ventral abdominal wall, consistent with buried bumper syndrome (BBS). She underwent G-tube exchange and was transferred back to the IRF.

Discussions: The pathophysiology of BBS is thought to occur when the internal fixation device of the cannula migrates alongside the stoma tract, ending up between the stomach mucosa and surface of the skin. Mild cases involve ulceration underneath the disc with hyperplastic tissue growing over the edge of the disc/balloon, while more aggressive cases can lead to gastric perforation, bleeding, peritonitis, or necrotizing fascitis. BBS more often occurs with rigid internal fixation devices or discs; however, in rare cases, such as this particular patient, BBS can occur with balloon type G-tubes as well.

Conclusions: BBS is an uncommon complication of G-tubes that occurs in roughly 1% of cases. Physiatrists who encounter patients with G-tubes in IRFs should be vigilant for BBS in cases of vague abdominal pain, especially in patients with impaired ability to communicate, such as those with TBI. A preventive measure for this syndrome is to ensure that the external bolster of the g-tube is at least 0.5-1cm from the abdominal wall and to rotate the g-tube 360 degrees daily.