No abstract

Buried bumper syndrome (BBS) occurs due to the overgrowth of gastric mucosa over the inner bumper of a gastrostomy tube. Various therapeutic approaches have been described for the management of BBS. However, no standardized clinical protocol deals with this complication. The authors describe their experience of dealing with BBS. Case notes of the patients undergoing percutaneous endoscopic gastrostomy (PEG) between February 2002 and December 2007 at their institute were reviewed retrospectively, and cases of BBS were analyzed. During this 71-month period, 356 PEG procedures were preformed. Seven patients with BBS were identified from the case note review (incidence of 1.97%). Attempts at endoscopic removal of the buried bumper were made but unfortunately failed. In view of the patients' associated comorbidity, the buried bumpers in these patients were left in situ, and a new PEG was inserted adjacent to the first site in 6 individuals. In 1 patient, a jejunal extension tube was inserted through the original PEG tube for feeding. No complications from the buried bumper arose in these patients during a median follow-up of 18 months (range, 1-46 months). Some patients being fed by a PEG tube are in poor general health and have significant comorbidities. They are therefore poor candidates for surgical or endoscopic removal of a buried bumper. In such patients, leaving the internal bumper in situ should be considered as a relatively safe treatment option.

CMC is not a well-recognised condition in gastroenterology practice and clinicians need to be aware of the genetics of the condition as well as the risk for oesophageal cancer so that they can counsel their patients and arrange surveillance appropriately.

logic symptoms revealed an elevated activated partial thromboplastin time (aPTT) of 92 seconds. Fifteen minutes after recanalization the ipsilateral MFV had normalized. At this time, CT showed right-sided hemorrhage in the basal ganglia (see the figure, D). Receiving intensive rehabilitation therapy, the patient became increasingly more mobilized with time; but 90 days later, he still depended on extensive help in his daily activities (Rankin score 4).In this case of hyperperfusion-induced ICH after PTA and stenting of the ICA, CBF velocity was continuously monitored by TCD before and at symptom onset. In the cases previously reported, postintervention hyperperfusion at symptom onset was assumed but not documented. 3-7 Such documentation, however, may be crucial for identifying patients at risk of ICH. The present case demonstrates that TCD can easily be performed during PTA and stenting.In summary, intracerebral hemorrhage is an increasingly recognized complication of PTA/stenting. Although its frequency has not yet been determined, it may exceed that of intracerebral hemorrhage after CEA. In the majority of cases, it is not preceded by reliable clinical symptoms, therefore peri-and postintervention monitoring is mandatory. Because TCD can be used to identify patients at risk, it may play an important role in the management of hyperperfusion in these patients, as well as help physicians to devise therapeutic strategies, such as careful control of even moderately elevated blood pressure, to avoid postintervention hemorrhage.

Follow-up data provide further evidence that the "cut and push" method is a safe and cost-effective method for removing 15 Fr PEG tubes in adult patients and that an abdominal radiograph is not routinely required.