Etiology: Placed in patients who need bowel decompression or who have trouble eating to provide nutrition
Imaging AXR AP: — Nasogastric tube (NG-tube) tip should be beneath the gastroesophageal junction and well into the stomach — A nasogastric 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 nasogastric 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 — A nasogastric tube that is too straight after placement and that does not gently curve into the stomach should be suspected of not being in the stomach — A nasogastric tube tip that projects over the pelvis should be suspected of not being in the stomach
DDX: Nasogastric tube mimics include esophageal temperature probe which has a twisted wire appearance, pH probe which has numerous linear marks along its length, NAVA tube which has pointed end and transesophgeal echocardiogram probe which has a very wide diameter and a sensor at the end
Complications: — Inability to advance the nasogastric tube into or through the nose due to pyriform aperture stenosis or choanal atresia — Inability to advance the nasogastric tube into the stomach due to esophageal atresia — Placement of the nasogastric tube tip into the airway or lung or pleural space can result in pneumothorax or aspiration with feedings — Placement of the nasogastric tube in the esophagus above the gastroesophageal junction — Looping of the nasogastric tube in the esophagus — Perforation of the esophagus or stomach during nasogastric tube placement — Kinking of the nasogastric tube leading to its obstruction — Trans-pyloric placement of the nasogastric tube tip
Treatment: Further advancement of proximally placed nasogastric tube, pulling back of transpylorically placed nasogastric tube, repositioning or replacement of kinked nasogastric tube
Clinical: — Presentations include abdominal distension and inability to infuse through nasogastric tube if kinked — Transpyloric placement of the nasogastric tube tip can result in a misdiagnosis of bilious emesis
Radiology Cases of Nasogastric Tube Coiled in Esophagus in 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.CXR AP (above left) shows the chest to be unremarkable aside from a right sided aortic arch. However, there is no air seen within the gastrointestinal tract. CXR lateral (above right) shows the proximal esophagus behind the trachea to be very dilated. CXR obtained after placement of a nasogastric tube (below) shows the nasogastric tube to be looped within the proximal esophagus.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.
Radiology Cases of Nasogastric Tube Placement Into Airway
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.CXR AP shows the tip of the nasogastric tube to be in the left mainstem bronchus.CXR AP shows a tracheostomy tube in normal position and a nasogastric tube whose tip is in the right lower lobe.
Radiology Cases of Nasogastric Tube Placement Into Airway Causing Tension Pneumothorax
Initial CXR AP (left) shows the course of the nasogastric tube to project over the right lung and the tip of the nasogastric tube projects over the liver and is probably in the right costophrenic sulcus. The remaining tubes and lines are in appropriate position. CXR AP obtained after removal of the nasogastric tube (right) shows a large amount of air in the right pleural space and there is mediastinal shift to the left.
Radiology Cases of Nasogastric Tube Placement Into 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.CXR AP shows the tip of the nasogastric tube looped back completely upon itself in the proximal esophagusCXR AP shows a nasogastric tube curling back upon itself within the esophagus with the tip of the nasogastric tube located above the thoracic inlet.
Radiology Cases of Nasogastric Tube Placement Causing Esophageal Perforation
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.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.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)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.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.AXR AP (above left) shows the nasogastric tube to follow a rather straight course into the abdomen. There is increased lucency in the upper abdomen. Subsequent AXR decubitus (above right) shows free air between the abdominal wall and liver. AP view obtained 9 days later immediately after the injection of water soluble contrast through the nasogastric tube (below left) shows some contrast extravasating out of the esophagus into the mediastinum and some contrast entering the stomach. Lateral view obtained 15 minutes later (below right) shows contrast outlining the left pleural space.Baseline CXR AP (left) shows the tip of the nasogastric tube to project appropriately over the body of the stomach. CXR AP after nasogastric tube replacement (right) shows the tip of the feeding tube to project over the right upper quadrant of the abdomen.
Radiology Cases of Nasogastric Tube Kinking
Supine AXR shows a nasogastric tube which courses to the pylorus and then kinks back upon itself
Radiology Cases of Nasogastric Tube Placement Into Duodenum
CXR AP shows the tip of the nasogastric tube to project near the ligament of Treitz.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.CXR AP shows the tip of the nasogastric tube projects over the second portion of the duodenum.
Radiology Cases of Nasogastric Tube Placement Into Duodenum Causing Bilious Residuals After Feeding and Clinically Mimicking Malrotation With Midgut Volvulus
AXR AP shows the tip of the nasogastric tube to be transpyloric in position, in the first part of the duodenum.
Radiology Cases of Nasogastric Tube Mimics
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. 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.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
