ageingAge AgeingageingAge and AgeingAge Ageing0002-07291468-2834Oxford University Press20410.1093/ageing/afi204Case ReportsBuried Bumper Syndrome complicated by intra-abdominal sepsis      WaltersGareth                            RameshP.                            MemonMuhammed Ibrahim                                      Department of Care of the Elderly, Solihull Hospital, Heart of England Foundation Trust, Lode Lane, Solihull, West Midlands B91 2JL, UKAddress correspondence to P. Ramesh. Fax (+44) 0121 424 4611. Email: parthasarathy.ramesh@heartofengland.nhs.ukNovember20053466506513820052872005© 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.org2005      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.          percutaneous endoscopic gastrostomy      dementia      buried bumper syndrome    hwp-legacy-fpage650cover-dateNovember 2005hwp-legacy-docheadCase Report              Introduction            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.                  Case report            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.                  Discussion            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.                  References                    1.        Gauderer MWl, Ponsky JL, Izant RJ. Gastrostomy without laparotomy: a percutaneous endoscopic technique. J Paediatric Surg 1980; 15 872–5.                    2.        Shallman RW, Norfleet RG, Hardache JM. Percutaneous endoscopic gastrostomy feeding tube migration and impaction in the abdominal wall. Gastrointest Endosc 1988; 34 367–68.                    3.        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.                    4.        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.                    5.        Ballester P, Ammori BJ. Laparoscopic removal and replacement of tube gastrostomy in the management of buried bumper syndrome. Int J Surg 2004; 5 2.                    6.        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.                    7.        Finucane TE, Christmas C, Travis K. Tube feeding in patients with advanced dementia. JAMA 1999; 282 1365–70.                    8.        Monteleoni C, Clark E. Using rapid cycle quality improvement methodology to reduce feeding tubes in patents with advanced dementia. BMJ 2004; 329 491–94.                                                        