History and clinical findings: A 65-year-old patient had a fracture of the skull with resulting swallowing disorder and underwent percutaneous endoscopic gastrostomy (PEG) 9 months previously. A specific home care and maintenance of the PEG was not provided. The patient was referred to our hospital because of haematemesis on the suspicion of upper gastrointestinal bleeding. He was in a generally reduced condition with the clinical signs of anaemia and with a positive shock index.
Investigations: The laboratory tests revealed an anaemia. The gastroscopy showed an active bleeding ulcer under the migrated internal bumper of the PEG (buried bumper syndrome). The bleeding activity was classified as Forrest lb. In addition, the chest X-ray and the bronchoscopy showed bilateral pneumonia.
Diagnosis, treatment and course: Summarizing the diagnoses there was an active bleeding ulcer in the sense of a buried bumper syndrome in combination with bilateral pneumonia caused by aspiration. After releasing the bumper the bleeding was stopped by local injection therapy. As additional treatment of the lesion it was aimed to lower pressure on the affected mucosal area. This was achieved by the use of a button gastrostomy with a liquid-filled retention balloon that was placed through the preexisting stoma. The pneumonia was treated with antibiotics. Follow-up gastroscopies revealed good healing of the ulcer and the patient was discharged.
Conclusions: The complication of a buried bumper syndrome with ulcer bleeding can effectively be treated by the use of a button gastrostomy. Treatment is based on sufficient pressure relief in the affected mucosa area. Advantages can be seen in the maintenance of the stoma and in the opportunity for an early continuation of enteral feeding.