Nasogastric Tube Malfunction / Malposition / Misposition / Misplacement

  • Etiology: placed in patients who need bowel decompression or who have trouble eating to provide nutrition
  • AXR:
    — nasogastric 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, 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 priform 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 / replacement of kinked nasogastric tube
  • Clinical: presentations include abdominal distension, inability to infuse through nasogastric tube if kinked, trans-pyloric placement of the nasogastric tube tip can result in a misdiagnosis of bilious emesis

Cases of Nasogastric Tube Malfunction / Malposition / Misposition / Misplacement

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