Pediatric Gastrostomy Tube Malfunction / Malposition / Misposition / Misplacement

Etiology: Placed in patients who require nutritional assistance
Imaging AXR:
— Correct position for the tip of a gastrostomy tube (G-tube) after placement or replacement should be over the stomach, any other position is suspect
— Any free air resulting from initial gastrostomy tube placement should resolve by several days after placement, free air in a symptomatic patient is suspect
Imaging Fluoroscopy:
— Extravasation of contrast into peritoneum or retroperitoneum
— Contrast filling small bowel or colon before or at same time stomach is filled
— Gastric outlet obstruction
DDX:
Complications:
— Malposition of the gastrostomy tube tip outside of the stomach
— Migration of gastrostomy balloon into abdominal wall tract
— Gastrostomy tube goes through bowel loop before entering the stomach (gastrocolic fistula)
— Gastric outlet obstruction from the retention balloon
— Gastrostomy tube leak or fracture
— Migration of the gastrostomy tube tip outside of the stomach
Treatment:
— Replacement of gastrostomy tube that is outside of stomach
— Decreasing size of gastrostomy balloon causing gastric outlet obstruction
Clinical: Presentations include what is being infused though the gastrostomy tube is being aspirated out of a nasogastric tube in the stomach, inability to infuse through gastrostomy tube, abdominal distension, vomiting

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

Radiology Cases of Gastrostomy Tube Correct Position in the Stomach

Upper GI of gastrostomy tube tip in the stomach — AP (above) and lateral (below) radiographs obtained after the injection of water soluble contrast through the gastrostomy tube show normal appearing gastric rugae. There is no leakage of contrast out of the stomach.

Radiology Cases of Gastrostomy Tube Placement Outside of Stomach

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.

Radiology Cases of Gastrostomy Tube Placement in the Peritoneal Cavity

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.

Fluoroscopy of gastrostomy tube tip in peritoneal cavity — AP radiograph of the abdomen after injection of water soluble contrast through the gastrostomy tube shows contrast outlining the spleen and several loops of small bowel. There is no contrast in the stomach.

AXR of the tip of the gastrostomy tube in the peritoneal space rather than in the stomach. — AXR AP obtained after the injection of water soluble contrast through the gastrostomy tube shows contrast throughout the peritoneum which is outling the liver and spleen and pooling in the pelvis. The contrast in the bladder is from a CT exam performed earlier in the day.

Radiology Cases of Gastrostomy Tube Placement in the Retroperitoneum

Gastrostomy tube injection showing tube in retroperitoneum — AP (left) and lateral (right) images after the injection of water soluble contrast through the gastrostomy tube show the injected contrast is not in the stomach but is outlining the haustra of the colon.

Radiology Cases of Gastrostomy Tube Placement Through Colon (Gastrocolic fistula)

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.

Radiology Cases of Gastrostomy Tube Balloon Causing Gastric Outlet Obstruction

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.

Radiology Cases of Gastrostomy Tube Tip Migration Outside of Stomach

CT of gastrostomy tube tip in subcutaneous tissues — Axial (above left) and sagittal (above right) CT with contrast of the abdomen shows the anchoring balloon and tip of the gastrostomy tube are in the subcutaneous tissues of the anterior abdominal wall rather than in the stomach. Lateral image from an injection of the gastrostomy tube (below) shows contrast flowing through the gastrostomy tube track and entering the stomach. Again, the gastrostomy tube anchoring balloon and tip of the gastrostomy tube are not in the stomach.

Fluoroscopy of gastrostomy tube tip inside its tract and outside of the stomach — Lateral image of the abdomen is obtained during injection of the gastrostomy tube shows that the gastrostomy tube balloon is outside of the stomach and contrast is flowing along the gastrostomy tube track into the stomach.