Infant who became unresponsive and underwent 30 minutes of CPR

CT of hypoperfusion complex / shock bowel in child abuse — Axial CT with contrast of the abdomen shows periportal edema in the liver, diffusely dilated and hyperenhancing loops of small bowel and a narrow caliber inferior vena cava.

The diagnosis was hypoperfusion complex in a child abuse patient.

Toddler who was abused who is vomiting after eating

Upper GI of duodenal hematoma in child abuse — AP image from an upper GI exam shows diffuse persistent narrowing of the lumen of the second and third portions of the duodenum.

The diagnosis was duodenal hematoma in a child abuse patient.

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.

Newborn with a distended abdomen and bilious aspirates

Surgical image of jejunal atresia — Surgical image shows dilation of the proximal jejunum with a blind end (to the left) and a distal apple-peel deformity with extensive atresias of the jejunum and ileum (to the right).

The diagnosis was jejunal atresia.

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.

Teenager being investigated for gastroesophageal reflux

CXR of pH probe — CXR AP shows a catheter which has numerous linear marks along its length projecting within the esophagus which represents a pH probe whose sensor port, which appears as a minus (-) sign, is in appropriate position 3-5 cm above the gastroesophageal junction

The diagnosis was gastroesophageal reflux with a mimic of a nasogastric tube.

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.

Teenager with bilious returns from the nasogastric tube

AXR of post-pyloric nasogastric tube — Supine AXR shows the tip of the feeding tube to be in the gastric body and the tip of the nasogastric tube to be in the third part of the duodenum – the exact opposite of what their normal positions should be.

The diagnosis was placement of the nasogastric tube tip post-pyloric in the duodenum.

Toddler whose nasogastric tube is not providing any suction

AXR of kinked nasogastric tube — Supine AXR shows a nasogastric tube which courses to the pylorus and then kinks back upon itself

The diagnosis was kinking of the nasogastric tube tip in the stomach.

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.

Premature newborn after nasogastric tube placement

AXR of gastric perforation from nasogastric tube placement — Supine AXR (above) shows increased lucency throughout the central abdomen and left lateral decubitus AXR (below) shows air between the abdominal wall and the liver. On both views the tip of the nasogastric tube projects inferior to the gas-filled stomach.

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

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.

Infant with hematemesis who had an unsuccessful nasogastric tube placement

CXR of esophageal perforation from nasogastric tube placement — CXR AP shows air outlining the heart in the pericardial space, air outlining the thymus in the mediastinum, and air in the bilateral pleural spaces.

The diagnosis was pneumopericardium, pneumomediastinum, and pneumothorax due to esophageal perforation from traumatic nasogastric tube placement. A subsequent esophagram did not demonstrate a leak.

Preschooler status post nasogastric tube placement

CXR of nasogastric tube looped in esophagus — CXR AP shows the tip of the nasogastric tube looped back completely upon itself in the proximal esophagus

The diagnosis was looping of the nasogastric tube in the esophagus.

Newborn status post nasogastric tube placement

CXR of nasogastric tube in mid-esophagus — CXR AP shows the tip of the nasogastric tube in the mid esophagus. The tip of the umbilical venous catheter is too high in the right atrium and the tip of the umbilical arterial catheter is too high in the aortic arch.

The diagnosis was placement of the nasogastric tube tip in the esophagus.

Infant with inadequate oral intake who just had a feeding tube placed

AXR of nasogastric tube in the lung — AXR shows the tip of the feeding tube to be in appropriate position in the second portion of the duodenum. The nasogastric tube tip is noted to be projecting over the heart in the left lower lobe of the lung.

The diagnosis was placement of the nasogastric tube tip into the lung.

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.

Newborn whose nasogastric tube cannot be advanced into the stomach

CXR of esophageal atresia — CXR AP shows a nasogastric tube looped upon itself forming a figure 8 in 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 with hemodynamic instability after gastrojejunostomy tube placement

AXR of pneumoperitoneum due to malposition of gastrojejunostomy tube outside of bowel — Supine AXR (above) shows the tip of the gastrojejunostomy tube extending deep into the pelvis. Left lateral decubitus AXR (below) shows air between the abdominal wall and the liver.

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.

School ager not tolerating their jejunostomy tube feeds well

Gastrojejunostomy tube injection showing appropriate position of the tube tip — AP image from a jejunostomy tube injection shows the tip of the jejunostomy tube in the jejunum. Subsequent image showed no evidence of downstream small bowel obstruction.

The diagnosis was normal position of the tip of the gastrojejunostomy tube.

School ager status post gastrojejunostomy placement

AXR showing gastrojejunostomy tube in appropriate position — AXR shows the tip of the gastrostomy tube projecting over the stomach and the tip of the gastrojejunostomy tube projecting near the duodenal-jejunal junction.

The diagnosis was normal position of the tip of the gastrojejunostomy tube.

Teenager vomiting after gastrostomy tube feedings

Gastrostomy tube injection showing gastric outlet obstruction from gastrostomy balloon — AP image from a gastrostomy tube injection shows a round filling defect in the antrum of the stomach. Only an extremely small amount of contrast was seen to empty out of the stomach after 30 minutes.

The diagnosis was gastric outlet obstruction caused by the gastrostomy tube balloon