Infant with respiratory distress

AXR of chylous ascites in child abuse
CXR AP (left) shows the lungs to be poorly expanded and clear but there are dense areas of callus along the lateral aspect of the right 3rd-5th ribs. Centralization of the loops of bowel were also incidentally noted and confirmed on a subsequent AXR AP (right).

The diagnosis was chronic right 3rd-5th lateral rib fractures and low lung volumes due to ascites which was found to be chylous when tapped in a child abuse patient.

Premature newborn after umbilical venous catheter placement

AXR of umbilical venous catheter misplacement in umbilical vein
AXR AP shows the tip of the umbilical venous catheter curling back upon itself within the umbilical vein. The tip of the umbilical arterial catheter projects at T6. The proximal small bowel is massively dilated.

The diagnosis was low malposition of the umbilical venous catheter and appropriate position of the umbilical arterial catheter in a patient with jejunal atresia.

Newborn with hypoxic ischemic encephalopathy

CXR of esophageal temperature probe
CXR AP shows a nasogastric tube coursing within the esophagus into the stomach while the twisted wire probe next to it with its tip in the mid-esophagus represents an esophageal temperature probe in appropriate position. The patient is lying upon a cooling blanket while being cooled to treat their hypoxic ischemic encephalopathy.

The diagnosis was a patient with hypoxic ischemic encephalopathy with a mimic of a nasogastric tube.

Preschooler on ECMO after cardiac surgery with a tube in the esophagus

CXR of transesophageal echocardiogram probe
CXR AP shows an open chest with an ECMO arterial catheter tip in the aortic arch and an ECMO venous catheter tip in the right atrium. A wide-diameter tube with a sensor at the end projects over the esophagus which represents a transesophageal echocardiogram probe.

The diagnosis was a patient on extracorporeal membrane oxygenation with a mimic of a nasogastric tube.

Premature newborn after nasogastric tube placement

AXR of gastric perforation from nasogastric tube placement
Supine and left lateral decubitus AXR (left) show a nasogastric tube with its tip deep in the pelvis without evidence of free air. Supine AXR taken after pulling the nasogastric tube back into the stomach (above right) shows increased lucency throughout the central abdomen and left lateral decubitus AXR taken at same time (below right) shows air between the abdominal wall and the liver.

The diagnosis was pneumoperitoneum due to gastric perforation during nasogastric tube placement which became visible only after the nasogastric tube was pulled out of the hole it had made in the stomach wall.

Newborn with distended abdomen after nasogastric tube placement

AXR of gastric perforation from nasogastric tube placement
Supine AXR (left) shows a large amount of air within the abdomen and air outlining both sides of bowel wall (Rigler’s sign) in the right lower quadrant. Supine AXR taken later after pulling back of the nasogastric tube out of the stomach shows visualization of the falciform ligament over the spine (American football sign)

The diagnosis was pneumoperitoneum due to gastric perforation during nasogastric tube placement.

Premature newborn with abdominal distension after nasogastric tube placement

AXR of esophageal perforation from nasogastric tube placement
Supine AXR (above) shows increased lucency in the upper abdomen. The cross-table lateral AXR (below) shows air between the anterior abdominal wall and the bowel. The nasogastric tube follows a very straight course and does not curve towards the stomach. Note on both views that the tip of the nasogastric tube does not project over the stomach. US performed subsequently showed the tip of the nasogastric tube was in the retroperitoneum and not in the stomach.

The diagnosis was perforation of the esophagus during nasogastric tube placement. In the operating room the pneumoperitoneum was found to be due to an ileal perforation.

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.