Pediatric Gastrojejunostomy Tube Malfunction / Malposition / Misposition / Misplacement

  • Etiology: Placed in patients who require nutritional assistance
  • Imaging AXR:
    — A gastrojejunostomy tube (GJ-tube) tip that crosses to the right of the spine and then heads superiorly before turning back to the left of the spine is most likely still in the stomach
    — A gastrojejunostomy tube tip that crosses to the right of the spine and then heads inferiorly before turning back to the left of the spine is most likely in the duodenum or jejunum
    — Correct position for the tip of a gastrojejunostomy tube after placement or replacement should be near the duodenal-jejunal junction, any other position is suspect
    — Any free air resulting from initial gastrojejunostomy tube placement should resolve by several days after placement, free air in a symptomatic patient is suspect
  • Imaging Fluoroscopy:
    — Extravasation of contrast into peritoneum
    — Contrast filling small bowel or colon before or at same time stomach is filled
    — Gastric outlet obstruction, jejunal obstruction at the level of the jejunostomy tube tip
  • DDX:
  • Complications:
    — Malposition of the gastrojejunostomy tube tip outside of the bowel
    — Gastrojejunostomy tube goes through bowel loop before entering the stomach (gastrocolic fistula)
    — Gastrojejunostomy tube tip initial placement is in stomach
    — Jejunal-jejunal intussusception caused by the jejunostomy tube tip
    — Downstream small bowel obstruction from other etiologies
    — Gastric outlet obstruction from the retention balloon
    — Gastrojejunostomy tube leak or fracture, migration of the jejunostomy tube tip outside of the small bowel
    — Jejunostomy tube tip being pulled back into the stomach
  • Treatment: Replacement of gastrojejunostomy tube that is outside of bowel or causing a jejunal-jejunal intussusception
  • Clinical:
    — Presentations include what is being infused though the gastrojejunostomy tube is being aspirated out of a nasogastric tube in the stomach, inability to infuse through gastrojejunostomy tube, abdominal distension, vomiting, abdominal pain
    — Indications for gastrojejunostomy tube placement include patients at risk for aspiration or unable to tolerate gastric feeding or with significant gastroesophageal reflux

Radiology Cases of Gastrojejunostomy Tube Malfunction / Malposition / Misposition / Misplacement

Radiology Cases of Gastrojejunostomy Tube Placement in Correct Position

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.
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.

Radiology Cases of Gastrojejunostomy Tube Placement Outside of Bowel

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.
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.

Radiology Cases of Gastrojejunostomy Tube Tip Being Placement in Peritoneal Cavity

Jejunostomy tube injection showing jejunostomy tube tip is in peritoneum.
AP image obtained after injection of contrast through the jejunostomy port shows that contrast is not in the jejunum and instead is in the peritoneum.

Radiology Cases of Gastrojejunostomy Tube Tip Being Pulled Back Into Stomach

AXR of gastrojejunostomy tube that has been pulled back into stomach
AP image obtained immediately after placement of a gastrojejunostomy tube and contrast injection through it (above) shows the tip of the gastrojejunostomy tube to be in good position in the proximal jejunum. AXR AP obtained 1 month later (below) shows the tip of the gastrojejunostomy tube to be in the stomach. A ventriculoperitoneal shunt is also present.
AXR of gastrojejunostomy tube malfunction due to migration of the tip of the jejunostomy tube back into the stomach
AXR taken after injection through the jejunostomy port of a newly placed gastrojejunostomy tube one month ago (above) shows the tip of the jejunostomy tube to be in the proximal jejunum. AXR taken today (below) shows that the tip of the jejunostomy tube has been pulled back into the antrum of the stomach.
Fluoroscopic study of jejunostomy tube tip migration into stomach
AXR (above) shows the tip of the jejunostomy tube projects over the body of the stomach. AP (below left) and lateral (below right) images obtained after injecting water soluble contrast through the jejunostomy port of the gastrojejunostomy tube shows contrast outlining the rugae of the stomach. There is no contrast in the duodenum or jejunum.

Radiology Cases of Gastrojejunostomy Tube Tip Causing Duodenal-Jejunal Intussusception

CT of gastrojejunostomy tube causing duodenal-jejunal intussusception
Axial (above) CT with contrast of the abdomen shows a round soft tissue mass to the right of the vertebral body that has a target sign appearance and that has a jejunostomy tube coursing in the center of it. Coronal CT (below) shows the soft tissue mass to be long in length and to comprise the second and third parts of the duodenum and the proximal jejunum and to have the jejunostomy tube coursing throughout its length.