Radiology Review

What’s Wrong With This Picture?

Clinician Reviews. 2015 October;25(10):12,17
Author(s):
Nandan R. Hichkad, PA-C, MMSc
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Portable KUB radiograph image

What is your impression?


A 90-year-old woman, admitted for altered mental status, just had a nasogastric tube placed to facilitate nutrition and medication delivery. The ICU nurse asks you to review an abdominal radiograph to confirm correct placement, since several attempts by various hospital personnel were required before they felt they had the tube in place. The patient is otherwise currently stable, per the nurse’s report. Her vital signs are stable, and she will arouse to minimal stimulation, although she continues to demonstrate confusion. Portable KUB radiograph is shown. What is your impression?


 

References

ANSWER
The radiograph shows an enteric tube passing through the gastrointestinal tract. However, it extends low into the left lower quadrant, loops around the right lower quadrant, and then heads up toward the left upper quadrant. Such a course is atypical and concerning for displaced position.

The radiologists concurred, and it was decided to instill some water-soluble contrast and repeat the KUB for further evaluation. That image is shown here. Note that the contrast does not appear to be in the stomach, as no gastric folds are visible. It accumulates in the left upper quadrant, under the diaphragm. Such a finding is concerning for possible gastric perforation.

The tube was promptly withdrawn, and urgent surgical consultation was obtained.

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