Buried bumper syndrome: where did that PEG tube go?!

Transcription

1 Buried bumper syndrome: where did that PEG tube go?! Poster No.: C-3158 Congress: ECR 2018 Type: Educational Exhibit Authors: I. Kavelj, N. BABIC, G. Lovrencic-Prpic, D. Zadravec; Zagreb/HR Keywords: Swallowing disorders, Obstruction / Occlusion, Inflammation, Localisation, Contrast agent-oral, Complications, Fluoroscopy, CT, Conventional radiography, Gastrointestinal tract, Abdomen, Stomach (incl. Oesophagus) DOI: /ecr2018/C-3158 Any information contained in this pdf file is automatically generated from digital material submitted to EPOS by third parties in the form of scientific presentations. References to any names, marks, products, or services of third parties or hypertext links to thirdparty sites or information are provided solely as a convenience to you and do not in any way constitute or imply ECR's endorsement, sponsorship or recommendation of the third party, information, product or service. ECR is not responsible for the content of these pages and does not make any representations regarding the content or accuracy of material in this file. As per copyright regulations, any unauthorised use of the material or parts thereof as well as commercial reproduction or multiple distribution by any traditional or electronically based reproduction/publication method ist strictly prohibited. You agree to defend, indemnify, and hold ECR harmless from and against any and all claims, damages, costs, and expenses, including attorneys' fees, arising from or related to your use of these pages. Please note: Links to movies, ppt slideshows and any other multimedia files are not available in the pdf version of presentations. Page 1 of 21

2 Learning objectives to get familiar with indications and procedure of percutaneous endoscopic gastrostomy (PEG) tube placement, to present possible procedure-related early and delayed complications that may occur accentuating imaging characteristics and to introduce buried bumper syndrome by showing pictorial examples (what radiologist should know). Page 2 of 21

3 Background Percutaneous endoscopic gastrostomy (PEG) provides a possibility of long-term enteral feeding to patients with neurologic deficits, swallowing disorders, patology of upper gastrointestinal/respiratory tract (oropharyngeal or esophageal tumors) and various hypercatabolic states (burns, short bowel syndrome, major traumas). There are actually two main indications - feeding access and gut decompression in patients with advanced abdominal malignancies causing chronic obstruction/ileus. There are few contraindications to PEG placement. Absolute contraindications include pharyngeal or esophageal obstruction, active coagulopathy and any other general contraindication to endoscopy. Relative contraindications are: the presence of oropharyngeal or esophageal cancer due to the potential seeding of the PEG tract with cancer cells, abdominal wall abnormalities (the presence of prior abdominal surgery, the presence of abdominal wall metastases, open abdominal wounds, or ventral hernia defects), hepatomegaly, splenomegaly, moderate or severe ascites, portal hypertension with gastric varices, recent myocardial infarction, hemodynamic instability and sepsis. PEG was first introduced in by Gauderer et al. The procedure is considered to be simple, safe and rapid. The fiberoptic gastroscope is inserted through the patient s mouth and advanced into the stomach. Inflated air distends stomach and mobilizes the liver, spleen and colon away from the gastrostomy site, bringing the anterior gastric wall in close contact with the abdominal wall. Then, smoothly tapered intravenous cannula is introduced across the abdominal and gastric walls with a quick motion to pierce all the layers without pushing the stomach away. A wire snare passed through the gastroscope is looped around the cannula after proper positioning has been assured. With the plastic sheath in place, the metallic needle is removed and a long silk thread is inserted. The thread is grasped with the snare of the endoscope as it exits from the plastic cannula. The string is brought out through the mouth together with the endoscope. A specially prepared 16 French de Pezzer (Mushroom) Page 3 of 21

4 catheter is lubricated and pulled in a retrograde fashion through the patient's mouth, esophagus and across the gastric and abdominal walls. Tension is applied on the catheter outside untile judged that the gastric and abdominal walls are in loose contact.. The catheter is anchored to the abdominal wall with 2 sutures of a strong synthetic material. A cross bar of heavy rubber tubing aids in the immobilization. The procedure has the advantages that general anesthesia is not usually required, abdominal wall relaxation is not essential, it can be done in patients with severe musculoskeletal deformities, and there is minimal discomfort in the postoperative period. The patients are observed for 24 hours and then fed. Page 4 of 21

5 Images for this section: Fig. 1: PEG procedure images/org/health/articles/4911-peg-tube-01.ashx Page 5 of 21

6 Findings and procedure details Complications PEG complications can be divided into three groups: complications of upper endoscopy, direct complications of the PEG procedure and post-procedural complications. Complications associated with upper endoscopy include cardiopulmonary compromise (most frequent), aspiration, hemorrhage and esophageal perforation. The most common but self-limiting PEG procedure-related complications is benign pneumoperitoneum (incidence of over 50 %). Colon injury may occur due to the displacement of the transverse colon over the anterior gastric wall. It usually presents with peritonitis and surgery is often required. Interposition of bowel, usually the splenic flexure, can also result in gastro-colo-cutaneous fistulae. The diagnosis is made using contrast radiography via the PEG tube. Small bowel, liver and splenic injuries and possible intraperitoneal and retroperitoneal bleeding are reported but very rare complications. Abdominal wall bleeding (i.e. rectus sheath hematoma) following PEG placement is most often caused by puncture of an abdominal wall vessel, it occurs soon after placement and it s manifested by hemorrhage around the PEG insertion site. Some of post-procedural complications are: peristomal pain, abscess and wound infection, necrotizing fasciitis, peristomal leakage, PEG site herniation, GI bleeding and ulceration, gastric outlet obstruction, ileus and gastroparesis, tumor implatation at PEG site, etc. In this educational exhibit we are focusing on buried bumper syndrome (BBS) and its imaging characteristics. Buried bumper syndrome Page 6 of 21

7 Buried bumper syndrome is infrequent (occuring in % patients) and usually late but very serious complication of PEG tube placement that can result in tube dysfunction, gastric perforation, bleeding, peritonitis or death. BBS occurs when the internal bumper of the PEG tube erodes into the gastric wall leading to ischemic necrosis and migration, lodging itself anywhere between the gastric wall and skin, causing variety of additional findings such as wound infection, peritonitis and necrotizing fasciitis. Obesity is considered as the most important risk factor although rapid weight gain, patient manipulation, gauze placement beneath the external bumper, chronic cough and tube manipulation by inexperienced personnel have been associated with BBS. Diagnosis of BBS is made clinically and usually confirmed endoscopically or with computed tomography. Page 7 of 21

8 Images for this section: Fig. 2: X-ray image and fluoroscopy of normally positioned PEG tube Page 8 of 21

9 Fig. 3: Normal PEG tube position confirmed by MRI Fig. 4: Patient with erosive gastritis, abscess formation and pneumoperitoneum Page 9 of 21

10 Fig. 5: CT images showing internal bumper eroding into very thickened gastric wall Page 10 of 21

11 Fig. 6: Malposition of PEG tube resulting in very subtle contrast material extralumination along the stomach and around the spleen presented as laminar hyperdense layer (red arrows). Page 11 of 21

12 Fig. 7: CT images of the abdomen depicting dislodgement of the internal bumper outside of the stomach with evidence of contrast extralumination within left paracolic space and anterior to the liver Page 12 of 21

13 Fig. 8: Malposition of the PEG tube: extralumination of contrast material into the left abdominal cavity Page 13 of 21

14 Fig. 9: Same patient as in Fig. 8. Page 14 of 21

15 Fig. 10: CT image demonstrates internal bumper migration in the subcutaneous tissue of the anterior abdominal wall with multiple inflammatory collections Page 15 of 21

16 Fig. 11: PEG tube dislocation and inflammatory changes of abdominal wall Page 16 of 21

17 Fig. 12: Malposition of the PEG tube and fistula formation between the tube and stomach; infection of the abdominal wall. Page 17 of 21

18 Fig. 13: PEG insertion site metastasis (arrow), probably seeded via endoscopy (A-C) in patient with known squamous cell carcinoma of hypopharynx (D-F). Page 18 of 21

19 Conclusion The emergency physicians, including radiologists, should be aware of historical, exam and imaging features that suggest buried bumper syndrome and distinguish it from other, more benign complications. Page 19 of 21

20 Personal information Ivana Kavelj, MD Radiology resident Department of Radiology UHC Sisters of Charity (KBC Sestre milosrdnice) Vinogradska cesta 29 Zagreb Croatia Page 20 of 21

21 References 1. Gauderer MWL, Ponski J, Izant RJ., Jr Gastrostomy without laparotomy: a percutaneous endoscopic technique. J Pediatr Surg. 1980;15: Schrag SP, Sharma R, Jaik NP, et al. Complications related to percutaneous endoscopc gastrostomy (PEG) tubes. A comprehensive clinical review. J Gastrointestin Liver Dis. 2007;16(4): Walter Geer, DO and Rebecca Jeanmonod, MD. Early Presentation of Buried Bumper Syndrome. West J Emerg Med September; 14(5): Saptarshi Biswas, Sujana Dontukurthy, Mathew G. Rosenzweig, Ravi Kothuru, and Sunil Abrol, "Buried Bumper Syndrome Revisited: A Rare but Potentially Fatal Complication of PEG Tube Placement," Case Reports in Critical Care, vol. 2014, Article ID , 4 pages, Cyrany J, Rejchrt S, Kopacova M, Bures J. Buried bumper syndrome: A complication of percutaneous endoscopic gastrostomy. World Journal of Gastroenterology. 2016;22(2): doi: /wjg.v22.i Lynch CR, Fang JC. Prevention and management of complications of percutaneous endoscopic gastrostomy (PEG) tubes. Pract Gastroenterol. 2004;28: Gençosmano#lu R, Koç D, Tözün N. The buried bumper syndrome: migration of internal bumper of percutaneous endoscopic gastrostomy tube into the abdominal wall. J Gastroenterol. 2003;38: Venu RP, Brown RD, Pastika BJ, et al. The buried bumper syndrome: a simple management approach in two patients. Gastrointest Endosc. 2002;56: Page 21 of 21