Medical Image of the Week: Dobhoff Tube Placement with Roux-En-Y Gastric Bypass

Figure 1. Abdominal X-ray after Dobhoff tube (DHT) placement to confirm accurate positioning. The distal tip of the feeding tube is in a loop of jejunum in patient status post gastrojejunostomy.

Figure 2. Gastrointestinal anatomy before and after Roux-en-Y gastric bypass procedure.

Roux-en-Y gastric bypass is one of the most commonly performed bariatric operations in the United States.  It involves partitioning a small gastric pouch off the proximal stomach and attaching that pouch directly to the intestine, thereby bypassing the large remainder of the stomach (1,2). Placing a Dobhoff tube (DHT) and confirming its placement can be challenging due to the change in anatomy after the procedure. Here, we have a 65-year-old woman who presented to the hospital with acute encephalopathy and acute hypoxic respiratory failure due to multifocal pneumonia requiring intubation and prolonged ICU stay. A DHT was inserted after intubation for feeding purposes. An abdominal X-ray was obtained to confirm placement of the DHT (Figure 1).  Normally the DHT tip should be placed in the 2^nd to 3^rd portion of the duodenum and would create a C-shaped tracing on the X-ray. However, in our patient who had history of Roux-en-Y, the DHT bypassed the duodenum and went straight down from the stomach to the jejunum as illustrated in Figure 1. It is important to be aware of this change in anatomy in patients who had a Roux-en-Y gastric bypass surgery in order to confirm accurate placement of DHT.

Hasan Ali¹ MD, Huthayfa Ateeli² MBBS, Bhupinder Natt²  MD FACP, and Sachin Chaudhary² MD.

¹Department of Medicine, Division of Internal Medicine and ²Division of Pulmonary, Critical Care, Sleep and Allergy

University of Arizona College of Medicine

Tucson, AZ USA

References

1. Smoot TM, Xu P, Hilsenrath P, Kuppersmith NC, Singh KP. Gastric bypass surgery in the United States, 1998–2002. Am J Public Health. 2006;96(7):1187–9. [CrossRef] [PubMed]
2. Santry HP, Gillen DL, Lauderdale DS. Trends in bariatric surgical procedures. JAMA. 2005;294(15):1909–17. [CrossRef] [PubMed]

Cite as: Ali H, Ateeli H, Natt B, Chaudhary S. Medical image of the week: Dobhoff tube placement with Roux-en-Y gastric bypass. Southwest J Pulm Crit Care. 2018;16(4):226-7. doi: https://doi.org/10.13175/swjpcc045-18 PDF 

Medical Image of the Week: Stomach Rupture

Figure 1. Cross table view of patient showing massively dilated abdomen.

Figure 2. Chest x-ray showing air under diaphragm (arrow).

A 61-year-old man was transferred from another hospital for further care. He had a history of oxygen-dependent chronic obstructive pulmonary disease in addition to congestive heart failure, hypertension and diabetes mellitus. He had been seen earlier in the day at his primary care physician’s office for a routine visit. Although he was asymptomatic, emergency medical services (EMS) were called because of significant hypoxemia detected by pulse oximetry. EMS noted that the patient said he “feels OK”. However, a decision was made to intubate the patient. Multiple failed intubation attempts failed and he suffered a cardiopulmonary arrest. He was successfully resuscitated and underwent a cricotracheotomy with an uncuffed endotracheal tube. When transferred his mouth was taped shut and his nose clamped. His abdomen was markedly distended and tympanic (Figure 1). A supine chest x-ray showed air under the diaphragm. Abdominal exploration showed a ruptured stomach which was repaired. He made an uneventful recovery.

The difficult airway outside the operating room can be problematic. While preparation for airway control are made, preoxygenation should be performed (1). The patient should be placed in the “sniffing” position and mask ventilation performed. Appropriate positioning - with the tragus of the ear elevated parallel to the sternum - may require special preparation in obese patients. When adequate preoxygenation is accomplished endotracheal intubation can be attempted. However, when endotracheal intubation fails and/or mask ventilation is inadequate a variety of advanced intubation techniques can be considered including a laryngeal mask airway, fiberoptic intubation, cricothyroidotomy, or transtracheal jet ventilation (1).

Confirmation of proper endotracheal tube placement should be completed in all patients (2). Physical examination methods such as auscultation of chest and epigastrium, visualization of thoracic movement, and fogging in the tube are not sufficiently reliable to confirm endotracheal tube placement. During intubation, direct visualization of the endotracheal tube passing through the vocal cords into the trachea, especially with the use of a videolaryngoscope, constitutes firm evidence of correct tube placement. Use of an end-tidal carbon dioxide detector (i.e., continuous waveform capnography, colorimetric and non-waveform capnography) to evaluate and confirm endotracheal tube position should be performed.  For patients in cardiac arrest and for those with markedly decreased perfusion other methods of confirmation such as an esophageal detector device, ultrasound, or bronchoscopy should be used.

Robert A. Raschke, MD

University of Arizona College of Medicine Phoenix

Phoenix, AZ USA

References

1. Langeron O, Amour J, Vivien B, Aubrun F. Clinical review: management of difficult airways. Crit Care. 2006;10(6):243. [CrossRef] [PubMed]
2. American College of Emergency Physicians. Verification of endotracheal tube placement. January 2016. Available at: https://www.acep.org/Clinical---Practice-Management/Verification-of-Endotracheal-Tube-Placement/#sm.00004sk8v7vduedxxs618zbgnij0n (accessed 1/24/18).

Cite as: Raschke RA. Medical image of the week: stomach rupture. Southwest J Pulm Crit Care. 2018;16(1):53-4. doi: https://doi.org/10.13175/swjpcc008-18 PDF