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A surprise case of colonic interposition
Radiography (2006) 12, 31e33
CASE REPORT
A surprise case of colonic interposition Robert Law * Gastrointestinal Fluoroscopy Unit, Department of Radiology, Frenchay Hospital, Bristol BS16 1LE, United Kingdom Received 7 February 2005; accepted 20 March 2005 Available online 24 May 2005
KEYWORDS Fluoroscopy; Radiographer; Intubation
Abstract Blind nasogastric intubation failure as a result of changes to the normal anatomical pathway is not uncommon. This case report is on fluoroscopically guided intubation in a patient in whom blind intubation failed as a result of what was subsequently found to be a colonic interposition with associated late complications. Fluroscopically guided nasogastric intubation is a safe and effective procedure that should always be considered when blind intubation has failed. ª 2005 The College of Radiographers. Published by Elsevier Ltd. All rights reserved.
Background A 46-year-old female was admitted to the Intensive Care Unit (ICU) via the Accident Unit following a road traffic accident on the motorway in which she sustained serious burns and bony injuries. To provide nutritional support, a number of attempts were made to pass a naso gastric tube on the ward. Mobile chest radiography was requested as no aspirate could be obtained despite repeated attempts at intubation. The resulting film (Fig. 1) demonstrated the looped tube over the right lung field. At this hospital clinical radiographers in the Gastrointestinal Fluoroscopy Unit provide a service passing problematic fine bore feeding tubes. This
* Tel.: C44 117 97012112; fax: C44 117 9753829. E-mail address: [email protected]
service is provided for diagnostic, therapeutic and interventional purposes when blind intubation is either unsuccessful or inappropriate. A request was made to the Unit for appraisal and assistance in this case because the feeding tube, sited on the ward, appeared to be passing into the right hemithorax.
Intubation A 55 inch 8 French gauge ‘Coreflo’ nasoenteric feeding tube (Merck) was passed freely to the upper third of the oesophagus at which point there was resistance to onward passage. On fluoroscopy the tube appeared to pass sharply to the right but without any apparent distress to the patient. Nonionic contrast (3 ml ultravist 240) was infused which outlined filling defects (Fig. 2). The appearance
1078-8174/$ - see front matter ª 2005 The College of Radiographers. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.radi.2005.03.005
32
R. Law
Figure 1 Mobile chest radiograph demonstrating a feeding tube in the right hemi thorax (arrowed).
was not consistent with an oesophago-bronchial fistula and so the tube was advanced and on a number of occasions contrast infused. Outlined was a long loop of dilated colon containing solid residue (Fig. 3). Using a combination of an 0.35 mm 260 cm, Amplatz superstiff guidewire and a JAG wire the tube was passed around the ‘S’ shape of the colon and through the diaphragmatic hiatus. At the junction between the colon and the gastric
Figure 3 Tortuous redundant colon, (arrowed) and colo-gastric stricture (arrowed).
fundus there was a stricture restricting passage into the stomach. Once the stomach had been intubated onward passage into the small bowel was achieved without incident. Subsequently information received from a hospital at which the patient had been admitted as a baby confirmed that the patient had had a colonic interposition for oesophageal atresia.
Discussion
Figure 2 Contrast outlining filling defects passing from the oesophagus towards the right side (arrowed).
Oesophageal atresia is a developmental abnormality in which normal canalisation of the upper gastrointestinal tract does not occur. Most commonly the upper oesophagus ends in a blind pouch and the lower limb of the oesophagus communicates with the trachea via a fistula. Early surgical repair is required. A well documented treatment option for oesophageal atresia is the replacing of the defective oesophagus with the interposition of the ascending or transverse colon.1 Both the appearance of a redundant tortuous colon2,3 and colo-gastric stricturing1 as demonstrated in this case are recognised as late complications of colonic interposition. Gastric transposition in children and infants has also been documented in cases of oesophageal atresia, corrosive injury, leiomyomatosis and refractory gastroesophageal reflux. A benefit of this
A surprise case of colonic interposition form of repair is reported to be the maintaining of gastrointestinal continuity with few complications.4
Conclusion Radiographer performed fluoroscopy guided intubation of fine bore feeding tubes is a safe and effective procedure. Changes to the normal anatomical pathway as a cause of blind intubation failure is, however, not uncommon and must always be considered as a possibility by the radiographer performing the intubation.
33
References 1. Ahmed SA, Sylvester KG, Hebra A, Davidoff AM, McClane S, Stafford PW, et al. Esophageal replacement using the colon: is it a good choice? J Pediatr Surg 1996 Aug;31(8):1026e30. 2. Christensen LR, Shapir J. Radiology of colonic interposition and its associated complications. Gastrointest Radiol 1986; 11(3):233e40. 3. Khan AR, Stiff G, Muhammed AR, Alwafi A, Ress BI, Lari J. Esophageal replacement with colon in children. Pediatr Surg Int 1998;13(2e3):79e83. 4. Hirschl RB, Yardeni D, Oldham K, Sherman N, Siplovich L, Gross E, et al. Gastric transposition for esophageal replacement in children: experience with 41 consecutive cases with special emphasis on esophageal atresia. Ann Surg 2002 Oct;236(4):531e9 [discussion 539e41].
CASE REPORT
A surprise case of colonic interposition Robert Law * Gastrointestinal Fluoroscopy Unit, Department of Radiology, Frenchay Hospital, Bristol BS16 1LE, United Kingdom Received 7 February 2005; accepted 20 March 2005 Available online 24 May 2005
KEYWORDS Fluoroscopy; Radiographer; Intubation
Abstract Blind nasogastric intubation failure as a result of changes to the normal anatomical pathway is not uncommon. This case report is on fluoroscopically guided intubation in a patient in whom blind intubation failed as a result of what was subsequently found to be a colonic interposition with associated late complications. Fluroscopically guided nasogastric intubation is a safe and effective procedure that should always be considered when blind intubation has failed. ª 2005 The College of Radiographers. Published by Elsevier Ltd. All rights reserved.
Background A 46-year-old female was admitted to the Intensive Care Unit (ICU) via the Accident Unit following a road traffic accident on the motorway in which she sustained serious burns and bony injuries. To provide nutritional support, a number of attempts were made to pass a naso gastric tube on the ward. Mobile chest radiography was requested as no aspirate could be obtained despite repeated attempts at intubation. The resulting film (Fig. 1) demonstrated the looped tube over the right lung field. At this hospital clinical radiographers in the Gastrointestinal Fluoroscopy Unit provide a service passing problematic fine bore feeding tubes. This
* Tel.: C44 117 97012112; fax: C44 117 9753829. E-mail address: [email protected]
service is provided for diagnostic, therapeutic and interventional purposes when blind intubation is either unsuccessful or inappropriate. A request was made to the Unit for appraisal and assistance in this case because the feeding tube, sited on the ward, appeared to be passing into the right hemithorax.
Intubation A 55 inch 8 French gauge ‘Coreflo’ nasoenteric feeding tube (Merck) was passed freely to the upper third of the oesophagus at which point there was resistance to onward passage. On fluoroscopy the tube appeared to pass sharply to the right but without any apparent distress to the patient. Nonionic contrast (3 ml ultravist 240) was infused which outlined filling defects (Fig. 2). The appearance
1078-8174/$ - see front matter ª 2005 The College of Radiographers. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.radi.2005.03.005
32
R. Law
Figure 1 Mobile chest radiograph demonstrating a feeding tube in the right hemi thorax (arrowed).
was not consistent with an oesophago-bronchial fistula and so the tube was advanced and on a number of occasions contrast infused. Outlined was a long loop of dilated colon containing solid residue (Fig. 3). Using a combination of an 0.35 mm 260 cm, Amplatz superstiff guidewire and a JAG wire the tube was passed around the ‘S’ shape of the colon and through the diaphragmatic hiatus. At the junction between the colon and the gastric
Figure 3 Tortuous redundant colon, (arrowed) and colo-gastric stricture (arrowed).
fundus there was a stricture restricting passage into the stomach. Once the stomach had been intubated onward passage into the small bowel was achieved without incident. Subsequently information received from a hospital at which the patient had been admitted as a baby confirmed that the patient had had a colonic interposition for oesophageal atresia.
Discussion
Figure 2 Contrast outlining filling defects passing from the oesophagus towards the right side (arrowed).
Oesophageal atresia is a developmental abnormality in which normal canalisation of the upper gastrointestinal tract does not occur. Most commonly the upper oesophagus ends in a blind pouch and the lower limb of the oesophagus communicates with the trachea via a fistula. Early surgical repair is required. A well documented treatment option for oesophageal atresia is the replacing of the defective oesophagus with the interposition of the ascending or transverse colon.1 Both the appearance of a redundant tortuous colon2,3 and colo-gastric stricturing1 as demonstrated in this case are recognised as late complications of colonic interposition. Gastric transposition in children and infants has also been documented in cases of oesophageal atresia, corrosive injury, leiomyomatosis and refractory gastroesophageal reflux. A benefit of this
A surprise case of colonic interposition form of repair is reported to be the maintaining of gastrointestinal continuity with few complications.4
Conclusion Radiographer performed fluoroscopy guided intubation of fine bore feeding tubes is a safe and effective procedure. Changes to the normal anatomical pathway as a cause of blind intubation failure is, however, not uncommon and must always be considered as a possibility by the radiographer performing the intubation.
33
References 1. Ahmed SA, Sylvester KG, Hebra A, Davidoff AM, McClane S, Stafford PW, et al. Esophageal replacement using the colon: is it a good choice? J Pediatr Surg 1996 Aug;31(8):1026e30. 2. Christensen LR, Shapir J. Radiology of colonic interposition and its associated complications. Gastrointest Radiol 1986; 11(3):233e40. 3. Khan AR, Stiff G, Muhammed AR, Alwafi A, Ress BI, Lari J. Esophageal replacement with colon in children. Pediatr Surg Int 1998;13(2e3):79e83. 4. Hirschl RB, Yardeni D, Oldham K, Sherman N, Siplovich L, Gross E, et al. Gastric transposition for esophageal replacement in children: experience with 41 consecutive cases with special emphasis on esophageal atresia. Ann Surg 2002 Oct;236(4):531e9 [discussion 539e41].