Toddler with abdominal distension 2 days after gastrojejunostomy tube placement

AXR and gastrojejunostomy tube injection of pneumoperitoneum due to malposition of the gastrojejunostomy tube outside of the bowel
Supine (above left) and left lateral decubitus (above right) AXR show no evidence of air between the abdominal wall and the liver but on the decubitus view several concerning air bubbles project over the liver and appear extra-lumenal. The gastrojejunostomy tube was exchanged for a gastrostomy tube and AP image from a gastrostomy tube injection with water soluble contrast (below) shows contrast extravasating inferiorly out of the duodenum at the junction of the second and third parts of the duodenum.

The diagnosis was initial malposition of the gastrojejunostomy tube outside of the bowel. In the operating room a perforation was found in the 4th part of the duodenum.

Infant who has just undergone a gastrostomy tube replacement which was technically difficult

Gastrostomy tube injection of gastromy tube malposition outside of stomach
AP image from a gastrostomy tube injection done with water soluble contrast (left) shows none of the injected contrast conforming to the lumenal contour of the stomach. AXR taken 15 minutes later (right) shows the extravasated contrast diffusing throughout the peritoneum and outlining loops of bowel and being excreted in the bladder.

The diagnosis was malposition of the gastrostomy tube replacement outside of the stomach.

Infant with vomiting after gastrostomy tube placement a week ago

Enema and gastrostomy tube injection showing gastrostomy tube that was placed through colon into stomach
AP image during an enema shows a fixed lumenal caliber change or filling defect caused by the gastrostomy tube balloon in the mid transverse colon. Early lateral image during gastrostomy tube injection with water soluble contrast (above right) shows the gastrostomy balloon and tip within the stomach. Later lateral image during gastrostomy tube injection (below right) shows contrast refluxing back from the stomach along the gastrostomy tube tract into the colon which is anterior to the stomach.

The diagnosis was initial malposition of the gastrostomy tube through the colon and then into the stomach.

Newborn with esophageal atresia with abdominal distension after gastrostomy tube placement 1 week ago

AXR of pneumoperitoneum due gastrostomy tube malposition causing gastric perforation
Supine AXR (left) shows a gastrostomy tube projecting appropriately over the stomach with a triangular lucency superior to the stomach. Left lateral decubitus AXR (above right) again shows the triangular lucency superior to the stomach but does not show air between the abdominal wall and liver. Cross-lateral AXR (below right) shows air between the anterior abdominal wall and liver.

The diagnosis was pneumoperitoneum due to gastric perforation after gastrostomy placement. In the operating room the patient was found to have ischemic necrosis of the greater curvature of the stomach.

Toddler with respiratory distress

CXR and CT of lymphatic malformation of the thymus
CXR AP obtained intially (left) shows a normal appearing exam with a normal appearing thymus. CXR AP obtained 10 days later for continued respiratory distress (right) showed interval development of an anterior mediastinal mass. Axial+coronal CT with contrast of the chest shows a large low density anterior mediastinal mass with multiple thin septations.

The diagnosis was lymphatic malformation of the thymus which had bled in the interval between the two exams.