Newborn whose nasogastric tube cannot be advanced into the stomach

CXR of esophageal atresia
Initial CXR AP (left) shows an air-filled dilated proximal esophagus to the left of the endotracheal tube. CXR lateral (right) taken later after nasogastric tube was placed and could not be advanced further shows interval decompression of the proximal esophagus. There is gas present in the stomach and bowel.

The diagnosis was esophageal atresia with distal tracheo-esophageal fistula.

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.

Preschooler with superior mesenteric artery syndrome who had a feeding tube placed into the third part of the duodenum 1 day ago that is now not working. AXR (not available) showed the tip had migrated into the right upper quadrant of the abdomen

US of feeding tube tip in main portal vein
Transverse US of the liver shows the echogenic tip of a feeding tube to be in the main portal vein in the center of the image. Note the posterior shadowing from the tip extending inferiorly from it.

The diagnosis was feeding tube malfunction due to migration of the feeding tube tip out of the duodenum into the main portal vein. In the operating room the feeding tube was seen to have eroded into the superior mesenteric vein and then into the main portal vein and it was removed without complication.

Infant after feeding tube placement

AXR of feeding tube in mainstem bronchus, lung and pleural space with tension pneumothorax
AXR obtained immediately after feeding tube placement (left) shows a feeding tube going down the left mainstem bronchus and then turning up into the lung and increased lucency in the left costophrenic angle presumably due to the feeding tube entering the left pleural space. AXR obtained a minute later after feeding tube repositioning (right) shows the tip of the feeding tube in the antrum of the stomach and a large left pleural air collection with mediastinal shift to the right.

The diagnosis was feeding tube malfunction due to placement of the feeding tube through the airway into the lung and pleural space causing a tension pneumothorax.

Preschooler with right hip pain for 2 weeks

CT of perforated appendicitis
AP radiograph of the right femur was unremarkable. Coronal STIR MRI of the right hip and femur was unremarkable aside from incidental bright pelvic free fluid noted just above the bladder. Coronal 2D reconstruction from a CT with IV and oral contrast of the abdomen shows a large complex fluid collection containing air and a central calcification in the right lower quadrant which was lying next to the psoas muscle.

The diagnosis was perforated appendicitis with an abscess containing an appendicolith.