case 4 question 2

Try again! if the PEG tube cannot be easily moved or rotated within the tract, do not attempt to forcibly remove it.

Correct! The patient’s symptoms and exam are consistent with buried bumper syndrome. It occurs when the internal bumper of the PEG migrates into the abdominal wall. It is thought to be due to excessive compression of tissue between the internal and external bumpers or fixation devices of the PEG tube. Incidence is around 1%. Classic presentation includes abdominal pain, leakage around the tube and inability to flush or loss of patency of the tube. Abdominal imaging to locate the position of the migrated bumper is recommended to localize the migrated bumper. A disc retained inside the stomach and completely covered by the overgrowing tissue can be released using some type of endoscopic dissection technique.A disc localized out of the stomach should be treated by surgery.

Try again! based on the clinical exam, and severe tenderness on attempts to rotate the tube within the tract, this does not appear to simply be a clogged PEG. Therefore, till the position of the migrated bumper is ascertained, no attempts should be made to insert a brush into the lumen of the tube to restore patency.