AJR 2005; 184:S132-S133
© American Roentgen Ray Society
Neonatal Obstructive Jaundice Caused by a Malpositioned Gastrostomy Tube
Matthew V. Sebastian1,2 and
Brian D. Coley3
1 Department of Radiology, Medical College of Ohio, Toldeo, OH.
2 Present address: Dotter Interventional Institute, Portland, OR
97239-3098.
3 Department of Radiology, Columbus Children's Hospital, 700 Children's Dr.,
Columbus, OH 43205.
Received April 30, 2004;
accepted after revision July 1, 2004.
Address correspondence to B. D. Coley
(bcoley{at}chi.osu.edu).
Introduction
First successfully performed more than 120 years ago by Verneuil
[1], gastrostomy tube placement
in the pediatric population is now common, performed most often for intestinal
atresias, neurologic and swallowing disorders, and other conditions in which
nutritional support is needed. As the procedure has become more common in the
last 40 years, many types of complications have been documented, including
tube obstruction and dislodgement, malpositioning of replaced tubes, stomal
leak, and tube migration and prolapse with or without gastric outlet
obstruction and intussusception
[1-3].
A rare complication is obstructive jaundice caused by migration of balloon
catheters into the duodenum
[4-7].
We present such a case in a neonate.
Case Report
A 36-week-old preterm boy with a history of polyhydramnios was diagnosed
with upper esophageal atresia with distal tracheoesophageal fistula. Fistula
ligation was performed on day-of-life 1, but primary esophageal reanastomosis
could not be performed. For enteric feeding, a surgical Stamm gastrostomy was
performed and a 12-French self-retaining Malecot tip gastrostube was placed.
Three weeks after surgery, the Malecot catheter was inadvertently dislodged
and was replaced with a 12-French Foley catheter, with a 5-cm3
balloon placed through the stoma. Follow-up radiography after contrast medium
injection showed satisfactory placement of the balloon within the gastric
antrum.
The boy subsequently had several episodes of transient jaundice. Two weeks
after gastrostomy tube replacement, the total bilirubin had risen from 0.2
mg/dL to 3.2 mg/dL with a direct fraction of 2.9 mg/dL (normal, <0.6
mg/dL), indicating biliary obstruction. When this episode did not resolve
after 2 days, a portable sonography examination was ordered for evaluation.
Sonography disclosed intrahepatic and extrahepatic biliary ductal dilatation
(Fig. 1A), although the most
distal portion of the common bile duct could not be visualized. The balloon of
the Foley gastrostomy tube was through the pylorus, seen just distal to the
duodenal bulb in the first portion of the duodenum
(Fig. 1B). Suspecting that this
was the cause of the child's obstructive jaundice, the Foley balloon was
deflated. Follow-up sonography after 2 hr revealed complete resolution of
biliary dilatation (Fig. 1C). The balloon was reinflated to avoid dislodgement during transfer to the
radiology department for fluoroscopic tube repositioning. Just before
fluoroscopy, sonography showed biliary dilatation that had recurred during the
1 hr of balloon inflation. Contrast medium injected in the gastrostomy tube
confirmed the balloon tip to be just distal to the pylorus, probably proximal
to the ampulla of Vater (Fig.
2A). The balloon was deflated and the tube withdrawn back into the
stomach, where it was reinflated, and tube was easily secured
(Fig. 2B). Although proximal
duodenal narrowing was present where the tube had been, there was no
impediment to gastric emptying. The patient has subsequently done well without
new episodes of jaundice.
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Fig. 1A. —36-week-old preterm boy with symptoms of obstructive
jaundice. Initial sonogram of the porta hepatis shows patent portal vein (PV)
and hepatic artery (HA) and biliary ductal dilatation
(arrowheads).
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Fig. 1C. —36-week-old preterm boy with symptoms of obstructive
jaundice. Sonogram 2 hr after balloon deflation shows hepatic artery (HA,
arrowhead) and portal vein (PV), but no biliary ductal
dilatation.
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Fig. 2A. —36-week-old preterm boy with symptoms of obstructive
jaundice. Fluoroscopic lateral view after contrast medium is injected through
gastrostomy tube outlines displaced balloon (arrowheads) with tube
tip in descending duodenum (D).
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Fig. 2B. —36-week-old preterm boy with symptoms of obstructive
jaundice. Fluoroscopic image after repositioning; the gastrostomy tube balloon
(B) is within the gastric antrum, with narrowing seen at balloon's previous
position in proximal duodenum (arrowhead).
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Discussion
Gastrostomy tube complications in adults and children are well documented
in the literature
[1-3].
Balloon catheters are more likely to migrate to the gastric outlet or into the
duodenum or small bowel as the result of gastric peristalsis, and larger
balloons may pre-dispose this in adults
[6]. Balloon catheter migration
in children is more common when catheters are placed closer to the pylorus
[1], and typically results in
symptoms of gastric or intestinal obstruction, which is relieved with proper
tube repositioning. The complication of gastrostomy tube migration that causes
obstructive jaundice has been reported previously in three adults
[4,
6,
7] and in an 11-year-old boy
[5]. A similar case involving
obstructive jaundice by a redundant nasoenteric feeding tube within the
proximal duodenum in a 4-year-old boy has also been reported
[8].
The common theme in these cases is obstructive jaundice secondary to a
malpositioned gastrostomy tube balloon within the duodenum, readily reversed
by balloon deflation and tube repositioning. The mechanism of obstruction in
these cases is unclear. Direct physical obstruction of the ampulla of Vater
[4,
6], duodenal intussusception
around the balloon with secondary ampullary distortion and obstruction
[7], and external compression
of the common bile duct by the balloon have all been postulated
[5].
In our case, the displaced balloon was in the very proximal duodenum,
making direct obstruction of the ampulla of Vater unlikely. We hypothesize
that the small lumen in this neonate and relatively large 5 cm3
balloon diameter caused external compression of the common bile duct coursing
posterior to the first portion of the duodenum. This would be an iatrogenic
Mirizzi's syndrome, with the episodic obstruction in our patient perhaps
modulated by patient position or varying balloon position. Abu Zidan et al.
[5] proposed a similar
mechanism of compression of the common bile duct against a thrombosed portal
vein in their 11-year-old patient, diagnosed by scintigraphy.
Although balloon catheter obstructive jaundice is rare, gastrostomy tube
migration is common. This should be considered when evaluating neonatal
jaundice in patients with gastrostomy tubes. Sonography is the preferred
technique for initial hepatobiliary evaluation in infants and children, and
with proper attention, the gastrostomy tube tip can be identified. Early
identification of prolapse and biliary obstruction may prevent the need for
additional radiologic diagnostic or interventional procedures.
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Introduction
Case Report
