Esophageal perforation - misplaced nasogastric tube

Case contributed by Amanda Er

Presentation

Admitted for community-acquired pneumonia. After-hours portable chest X-ray requested to assess nasogastric tube placement. Ward nurses unable to obtain any aspirate.

Patient Data

Age: 85 years
Gender: Female

Chest and neck x-ray

x_ray

The tip of the nasogastric tube is in the stomach. However, the proximal portion of the tube has coiled in the esophagus. New-onset cervical emphysema is seen in the additional neck image. No pneumothorax is noted.

A CT scan of the neck, chest and abdomen was then performed the next day to determine the extent of the esophageal perforation.

CT neck, chest and abdomen

ct

1. An anomalous path of the nasogastric tube is seen, with a mostly submucosal course from the proximal esophagus to the distal esophagus. There is possible esophageal perforation at two sites:

i. At the level of T1, where the nasogastric tube likely enters the submucosal layer beyond the mucosal margins of the proximal esophagus, forming a false lumen.

ii. The nasogastric tube in the submucosal plane/false lumen appears to re-enter the true esophageal lumen at the distal esophagus, following the path of the esophagus into the stomach. However, the actual re-entry point is not confidently identified as the distal esophagus is collapsed.

There is resultant extensive mediastinal and cervical emphysema, as well as, extensive mediastinitis. No drainable mediastinal collection is seen. 

Associated near-complete collapse consolidation of the left lower lobe is likely
due to ongoing pneumonia. 

2. No mucosal defect is seen in the stomach to suggest perforation. No definite pneumoperitoneum. Gas anterior to the pancreas in the upper abdomen is deemed intraluminal gas of the duodenal cap.

Case Discussion

The radiographer who had performed this portable case had noted the coiled nasogastric tube (NGT) upon acquiring the chest image. It was initially assumed on the chest image that the lucencies noted over the left side of the patient's neck was artefact from the patient's hair. An additional frontal neck image was then initiated to determine the extent of the coiled NGT in the upper gastrointestinal tract.

However, not only did the neck image show several coiled loops of the NGT, there was also significant left-sided subcutaneous emphysema. This raised the suspicion of an esophageal perforation, a rare yet serious medical emergency with a high mortality rate of 25 to 50% in some cases 1-3.

On the subsequent CT scans, emphysema and mediastinitis as complications of the esophageal perforation were noted. The patient went on to have the perforated esophagus fixed intraoperatively.

In locations with only junior on-call doctors and minimal to no radiologists staffing after-hours, radiographers/radiologic technologists have to be vigilant in assessing their images for any critical medical emergencies when conducting portable x-ray examinations.

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