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: ICU Chest X-Ray

Figure 1. ICU portable chest x-ray. A: cardioversion pads. B: oro-gastric tube. C: right internal jugular dialysis catheter. D: endotracheal tube. E: left internnal jugular central venous catheter, incidentally seen terminating within the azygous vein. F: external EKG lead. G: chest tubes. H: staples along the thoracotomy incision. I: left lower lobe atelectasis and small pleural effusion.

A chest x-ray is probably the most commonly obtained radiographic image in the intensive care unit (ICU). Although not supported by evidence and recommended against, daily chest x-rays, especially in the intubated patients, are done in many ICUs (1,2). Multiple hardware placed for the support of the patient need to be identified for placement, position and potential complications. These can make reading a radiograph challenging specially the mediastinum. The accompanied radiograph serves as an example of an “ICU chest x-ray” with multiple “tube and lines”.

Janet Campion MD and Bhupinder Natt MD

Division of Pulmonary, Allergy, Critical Care and Sleep

Banner-University Medical Center, Tucson (AZ)

References

1. Oba Y, Zaza T. Abandoning daily routine chest radiography in the intensive care unit: meta-analysis. Radiology. 2010 May;255(2):386-95. [CrossRef] [PubMed]
2. http://www.choosingwisely.org/wp-content/uploads/2015/02/SCCM-Choosing-Wisely-List.pdf 

Cite as: Campion J, Natt B. Medical image of the week: ICU chest x-ray. Southwest J Pulm Crit Care. 2017;14(1):39. doi: https://doi.org/10.13175/swjpcc007-17 PDF

Medical Image of the Week: NG Tube Misplacement with a Pneumothorax

Figure 1.  CXR AP view showing misplaced NG tube in the right lung with small pneumothorax.

Figure 2. Follow up CXR AP view showing enlarged right pneumothorax after withdrawal of the NG tube.

Figure 3. CXR AP view post chest tube placement showing reinflation of the right lung.

Nasogastric tube (NG) placement is a common procedure performed in the inpatient hospital setting. They are often challenging to insert and therefore carry a risk of tracheobronchopleural, intravascular and enteral complications.

Our patient is a 90-year-old man who was admitted to the hospital with complaints of productive cough, fever, worsening of shortness of breath and confusion. He was diagnosed with viral upper respiratory tract infection, Legionella pneumonia and exacerbation of heart failure. Throughout his hospitalization patient had repeated episodes of delirium and had failed a swallowing evaluation. A NG was inserted for administration of enteral feeds and medications. There was no resistance to the passage of the tube when initially placed. However, post procedure CXR showed a misplaced nasogastric tube going into the right main bronchus and down into right lower lobe with a small apical pneumothorax (Figure 1). Follow up chest X-ray two hours later showed enlargement of the pneumothorax (Figure 2).  A 14 Fr pigtail catheter was promptly inserted in right pleural space. A repeat chest X-ray confirmed placement of the chest tube and showed re-inflation of the lung (Figure 3).

The reported incidence of misplacement of nasogastric tubes into the airways ranges from 0.3% to 15% and is more common after chest trauma or mechanical ventilation (1). This may be because of the need for adequate coordination of swallowing. Nasogastric tubes are generally considered safe, but there is a risk of significant pulmonary complications from blind insertion of small-caliber nasogastric tubes with a stiff stylet, particularly in elderly patients with altered mental status as well as with poor swallowing function (2).

Santhosh G. John MD, Vivian Keenan MD, Naveen Tyagi MD, and Priya Agarwala MD

Division of Pulmonary and Critical Care Medicine

Winthrop University Hospital

Mineola, New York USA

References

1. Agha R, Siddiqui MR. Pneumothorax after nasogastric tube insertion. JRSM Short Rep. 2011 Apr 6;2(4):28. [CrossRef] [PubMed]
2. Nazir T, Punekar S. Images in clinical medicine. Pneumothorax--an uncommon complication of a common procedure. N Engl J Med. 2010 Jul 29;363(5):462. [CrossRef] [PubMed] 

Cite as: John SG, Keenan V, Tyagi N, Agarwala P. Medical image of the week: NG tube misplacement with a pneumothorax. Southwest J Pulm Crit Care. 2017:14(1):14-5. doi: https://dx.doi/10.13175/swjpcc133-16 PDF