One of the private docs sends a patient in to be evaluated from a local nursing home, along with an order for a CT scan of the abdomen. The fellow is a 76-year-old post-CVA and with dementia, and the nursing home staff noted that he had some swelling near the site of his recently replaced G-tube. The G-tube also will not flush, which you confirm. By exam, the patient appears dehydrated, is tachycardic and moans in pain when the stomach is pressed. There is no rebound. Guy looks like a clear admission, just need to sort out the G-tube problem and rule out a perforation after the recent tube replacement. Some plain films have already been run (right), and the CT scan is pending. The study has been ordered with oral contrast – a bit of overkill since non-contrast would probably do fine – and the nurse is gently encouraging the patient to sip the brightly-colored contrast through a straw.
Some eons later, the scan is done, and the patient is ready for disposition. What does the scan show?
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Well now we know where the G-tube feedings have been going for the last several days: Into the subcutaneous tissue of the abdominal wall and flank! This goes to show how recent procedures, even apparently simple and easy ones (like replacing a G-tube), can often be the culprit in a patient with new problems and symptoms.
The CT scan shows not only the G-tube near the skin, but the balloon inflated just beneath the skin (and not in the stomach). There is a large amount of subcutaneous air and debris in the left anterior abdominal wall and flank, corresponding to the swelling on examination. The rest of the CT is unremarkable. The gastrografin study (also overkill in this case) shows the contrast pooling in one region, but not flowing into the bowel and outlining the lumen of the stomach and duodenum like it should.
After some head-scratching and a few phone calls to the surgeon and attending, we elected to enlarge the G-tube site opening at the skin and slowly compress the material out. Gross but effective. Admission for conservative management, Dobhoff placed for temporary feeding, and on with the show.
Dr. Dallara practices EM in Virginia and North Carolina and directs the EM PREP Course. www.emprepcourse.com