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
The tip of the nasogastric tube is in the stomach. However, the proximal portion of the tube has coiled in the oesophagus. 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 oesophageal perforation.
1. An anomalous path of the nasogastric tube is seen, with a mostly submucosal course from the proximal oesophagus to the distal oesophagus. There is possible oesophageal 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 oesophagus, forming a false lumen.
ii. The nasogastric tube in the submucosal plane/false lumen appears to re-enter the true oesophageal lumen at the distal oesophagus, following the path of the oesophagus into the stomach. However, the actual re-entry point is not confidently identified as the distal oesophagus 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
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 oesophageal 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 oesophageal perforation were noted. The patient went on to have the perforated oesophagus 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.
Unable to process the form. Check for errors and try again.