(Radiology. 2000;216:112-116.)
© RSNA, 2000
Congenital Diaphragmatic Hernia in Neonates: Variations in Umbilical Catheter and Enteric Tube Position1
Minako Sakurai, MD,
Lane F. Donnelly, MD,
Lance A. Klosterman, MD 2 and
Janet L. Strife, MD
1 From the Department of Radiology, Division of Pediatric Radiology, Duke University Medical Center, Durham, NC (M.S., L.F.D.), and the Department of Radiology, Children's Hospital Medical Center and University of Cincinnati College of Medicine, Ohio (L.A.K., J.L.S.). Received September 21, 1999; revision requested November 5; revision received November 19; accepted December 7. Address correspondence to L.F.D., Department of Radiology, Children's Hospital Medical Center, 3333 Burnet Ave, Cincinnati, OH 45229-3039 (e-mail: donnelly.lf@chmcc.org).
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ABSTRACT
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PURPOSE: To evaluate anatomic variations of support apparatus position on radiographs obtained in neonates with congenital diaphragmatic hernia (CDH).
MATERIALS AND METHODS: The authors evaluated radiographs obtained in 71 neonates with CDH to determine whether nasogastric tubes, umbilical venous catheters, and umbilical arterial catheters deviated from their expected anatomic course. The relationship between deviation patterns and hernia contents was evaluated.
RESULTS: Sixty-eight neonates—54 with left-sided CDH and 14 with right-sided CDH—had a nasogastric tube. The tubes in 21 patients with left-sided CDH had a normal anatomic course at radiography. Nineteen of these patients did not have stomach in the hernia. In 13 patients, the tip of the nasogastric tube was lodged at the esophagogastric junction. In 17 patients, the tube was in the left hemithorax. In all 30 of these patients, the stomach was within the CDH. All nasogastric tubes in the 14 patients with right-sided CDH had leftward deviation. Thirty-seven patients—27 with left-sided CDH and 10 with right-sided CDH—had umbilical venous catheters. The catheters in 12 patients with left-sided CDH had apex leftward convexity. The umbilical venous catheter in eight patients with right-sided CDH had rightward shift; all eight patients had liver herniation.
CONCLUSION: The positions of nasogastric tubes and umbilical venous catheters vary in several predictable patterns in neonates with CDH. Knowledge of these variations may be helpful for supporting the diagnosis of CDH in unclear cases and thus avoiding unnecessary apparatus adjustments, and for predicting hernia contents.
Index terms: Catheters and catheterization, in infants and children • Hernia, diaphragmatic, 70.15 • Infants, newborns
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INTRODUCTION
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Most children with congenital diaphragmatic hernia (CDH) present with severe respiratory distress during the first 24 hours of life and are cared for in neonatal intensive care units. Support apparatus (eg, umbilical arterial catheters, umbilical venous catheters, and orogastric or nasogastric tubes) are often placed in these children for intensive care. Because of the abnormal position of the stomach, liver, and other abdominal contents in many patients with CDH, the support apparatus can demonstrate courses that vary from normal at radiography. We postulated that knowledge of these variations may be helpful for supporting the diagnosis of CDH in unclear cases and thus avoiding unnecessary apparatus adjustments, and for predicting hernia contents. The purpose of this study was to evaluate the anatomic variations in support apparatus position on the initial radiographs obtained in neonates with CDH.
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MATERIALS AND METHODS
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The records from two children's medical centers (Children's Hospital Medical Center and Duke University Medical Center) from the years 1989 to 1998 were retrospectively searched for all neonates with a proved diagnosis of CDH. Seventy-one neonates (24 boys, 47 girls) with CDH who met the following criteria were identified: They were admitted to a neonatal intensive care unit and underwent radiography of the chest and abdomen on the 1st day of life. The radiographs were evaluated for the presence, course, and tip position of nasogastric or orogastric tubes, umbilical venous catheters, and umbilical arterial catheters. Two radiologists (M.S. and L.F.D. or L.A.K. and J.L.S.), who were blinded to the results of surgery or autopsy, retrospectively reviewed each radiograph together. Conclusions were reached by means of consensus. Both radiologists were aware that the radiographs had been obtained in neonates with CDH.
The patterns of tube and catheter deviation from the expected anatomic course (1,2) were noted. For each tube, both the tip position and the curvature along the course of the tube (apex leftward or apex rightward convexity) were noted. The nasogastric tube was classified as following its expected course if it traversed the mediastinum overlying the thoracic spine and demonstrated a slight apex rightward curvature. The tip position was classified as normal if it was within the expected anatomic position of the stomach within the left upper quadrant of the abdomen with any associated degree of rightward curvature along the greater curvature of the stomach.
An umbilical venous catheter was determined to have a normal course if it traversed the liver in the expected anatomic location of the ductus venosus and inferior vena cava overlying the thoracolumbar vertebral bodies, usually along the rightward aspect of the vertebral bodies. Lack of angulation of the catheter or gentle apex rightward angulation was considered to be normal. All marked angulations not related to patient positioning were considered to be deviations from the expected course. Normal tip position was defined as the tip being in the region of the junction of the right atrium and inferior vena cava.
An umbilical arterial catheter was determined to have a normal course if it ascended into the abdomen and thorax overlying the expected course of the descending aorta, over the thoracolumbar vertebral bodies, usually along the leftward aspect. At our institutions, a "high" umbilical arterial catheter position is preferred, with the tip of the catheter positioned in the descending thoracic aorta above the T11 level.
The deviation patterns of the catheters and tubes were correlated with whether the hernia contained stomach or liver. The hernia contents were determined by using surgical reports, autopsy reports, or ultrasonographic findings, when available. The surgical and autopsy reports were reviewed by one radiologist (M.S.) after the review of the radiographs was completed. In cases in which such documentation was not available, the hernia contents were determined on the basis of the opacity of gas and soft tissue on radiographs. The radiographic criteria for the presence of stomach within the hemithorax included the presence of an air-distended viscus, the diameter and configuration of which were suggestive of stomach in the thorax, together with the absence of such a structure in the abdomen. Liver was considered to be within the hernia when prominent soft tissue was present within the thorax. In some cases, the hernia contents were indeterminate.
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RESULTS
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The hernia was on the right in 16 patients and on the left in 55. Sixty-eight neonates had a nasogastric tube. In these 68 patients, the CDH was on the left in 54 patients and on the right in 14. In 21 of the 54 patients with a left-sided hernia, the nasogastric tubes had the expected anatomic course and tip position at radiography. The tubes in the other 33 patients demonstrated two patterns of deviation (Fig 1a, 1b). In 13 of the 33 patients, the tip of the nasogastric tube was at the expected location of the esophagogastric junction (Fig 1b), the level at which the person placing the tube met increased resistance when attempting to further advance the tube. In 17 of the 33 patients, the nasogastric tube traversed the mediastinum and entered the left upper quadrant of the abdomen but then turned superiorly with the tip of the catheter positioned within the left hemithorax (Fig 1c). With both of these patterns, there was often a prominent apex rightward curvature of the nasogastric tube as it traversed the mediastinum (Fig 1a). The degree of this angulation, however, varied. In three of the 33 patients, the nasogastric tube was not completely advanced and was positioned with the tip in the expected location of the middle region of the esophagus.
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Figure 1a. Frontal radiographs obtained in neonates with left-sided CDH on the 1st day of life demonstrate patterns of nasogastric tube course deviation. (a) Radiograph in a male neonate shows that the tip of the nasogastric tube is in the expected position in the stomach, in the left upper quadrant of the abdomen. Note the apex rightward convexity (arrow) of the thoracic portion of the tube. (b) Radiograph in a female neonate shows that the tip of the nasogastric tube (arrow) is lodged at the level of the esophageal gastric junction. Note the apex rightward convexity of the thoracic portion of the tube. (c) Radiograph in a male neonate shows the tip (large arrow) of the nasogastric tube positioned in the left hemithorax. Note the marked apex leftward angulation of the umbilical venous catheter (small arrow).
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Figure 1b. Frontal radiographs obtained in neonates with left-sided CDH on the 1st day of life demonstrate patterns of nasogastric tube course deviation. (a) Radiograph in a male neonate shows that the tip of the nasogastric tube is in the expected position in the stomach, in the left upper quadrant of the abdomen. Note the apex rightward convexity (arrow) of the thoracic portion of the tube. (b) Radiograph in a female neonate shows that the tip of the nasogastric tube (arrow) is lodged at the level of the esophageal gastric junction. Note the apex rightward convexity of the thoracic portion of the tube. (c) Radiograph in a male neonate shows the tip (large arrow) of the nasogastric tube positioned in the left hemithorax. Note the marked apex leftward angulation of the umbilical venous catheter (small arrow).
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Figure 1c. Frontal radiographs obtained in neonates with left-sided CDH on the 1st day of life demonstrate patterns of nasogastric tube course deviation. (a) Radiograph in a male neonate shows that the tip of the nasogastric tube is in the expected position in the stomach, in the left upper quadrant of the abdomen. Note the apex rightward convexity (arrow) of the thoracic portion of the tube. (b) Radiograph in a female neonate shows that the tip of the nasogastric tube (arrow) is lodged at the level of the esophageal gastric junction. Note the apex rightward convexity of the thoracic portion of the tube. (c) Radiograph in a male neonate shows the tip (large arrow) of the nasogastric tube positioned in the left hemithorax. Note the marked apex leftward angulation of the umbilical venous catheter (small arrow).
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The presence or absence of the stomach within the hernia was documented in 64 of the 68 patients with a nasogastric tube. The stomach position could not be determined in four patients. The stomach position was documented with surgery in 16 patients, at autopsy in two, and at radiography in 46. In 20 of the 21 patients with left-sided CDH in whom the nasogastric tube showed the expected anatomic course at radiography, the presence or absence of stomach within the hernia was documented. Of those 20 patients, 19 (95%) did not have stomach within the hernia. The presence or absence of stomach within the hernia was documented in 27 of the 30 patients in whom the nasogastric tube was lodged at the esophagogastric junction or in whom the tip of the tube was in the left hemithorax. The stomach was contained within the hernia in all 27 of these patients. Therefore, the presence of one of the two deviations in the pattern of nasogastric tubes was both sensitive and specific for predicting the presence or absence of stomach within the hernia.
None of the nasogastric tubes in the 14 patients with a right-sided CDH had the expected anatomic course at radiography. All were deviated to the left in one of three patterns. Three tubes were normally positioned within the superior thorax but were shifted into the left hemithorax within the lower thorax (Fig 2a). Three tubes were oriented vertically throughout the thorax but positioned to the left of the thoracic vertebral bodies (Fig 2b). Six tubes demonstrated apex convexity to the left instead of to the right. In two patients, the tips of the nasogastric tubes were lodged at the esophagogastric junction. None of the patients with right-sided CDH and nasogastric tubes had stomach within the hernia.
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Figure 2a. Frontal radiographs obtained in neonates with right-sided CDH on the 1st day of life demonstrate patterns of nasogastric tube course deviation. (a) Radiograph in a male neonate shows that the nasogastric tube (arrow) deviates to the left of the thoracic vertebral bodies as it passes through the inferior portion of the thorax. (b) Radiograph in another male neonate shows that the nasogastric tube (arrow) traverses the mediastinum with apex leftward angulation and is positioned to the left of the thoracic vertebral bodies. The intraabdominal portion of the tube is positioned within the right upper quadrant within the stomach.
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Figure 2b. Frontal radiographs obtained in neonates with right-sided CDH on the 1st day of life demonstrate patterns of nasogastric tube course deviation. (a) Radiograph in a male neonate shows that the nasogastric tube (arrow) deviates to the left of the thoracic vertebral bodies as it passes through the inferior portion of the thorax. (b) Radiograph in another male neonate shows that the nasogastric tube (arrow) traverses the mediastinum with apex leftward angulation and is positioned to the left of the thoracic vertebral bodies. The intraabdominal portion of the tube is positioned within the right upper quadrant within the stomach.
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Thirty-seven patients had an umbilical venous catheter. Twenty-seven of the 37 patients had left-sided CDH, and 10 had right-sided CDH. In none of the 27 patients with left-sided CDH did the catheter follow the expected anatomic course. There were three patterns of deviation: In seven patients, the catheter deviated toward the right, with the catheter tip positioned in the proximity of the deviated right atrium (Fig 3a). In eight patients in whom the liver was in the expected anatomic position, the tip of the catheter was in the portal venous system (Fig 3b). In 12 patients, the umbilical catheters demonstrated a mild to marked apex leftward convexity (Fig 1c) with various tip positions. None of the patients in whom the catheter either showed rightward deviation or was within the portal venous system had liver herniation. Of the 12 patients in whom the catheter had apex leftward convexity, five had liver within the hernia.
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Figure 3a. Frontal radiographs obtained in neonates with left-sided CDH on the 1st day of life demonstrate patterns of umbilical venous catheter course deviation. The pattern of marked apex leftward angulation of the umbilical venous catheter is demonstrated in Figure 1c. (a) Radiograph in a female neonate shows that the umbilical venous catheter (large arrow) is deviated to the right. Note that the umbilical arterial catheter (small arrow) also is deviated to the right. The tip of the nasogastric tube is in the left part of the abdomen within the expected anatomic location of the stomach, with prominent apex rightward convexity of the intrathoracic portion. (b) Radiograph in a male neonate shows that the umbilical venous catheter (large arrow) is positioned within the right portal vein. The umbilical arterial catheter has the expected course, with the tip at the T10 level. Note that the tip (small arrow) of the nasogastric tube is in the left side of the abdomen, within the expected anatomic location of the stomach.
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Figure 3b. Frontal radiographs obtained in neonates with left-sided CDH on the 1st day of life demonstrate patterns of umbilical venous catheter course deviation. The pattern of marked apex leftward angulation of the umbilical venous catheter is demonstrated in Figure 1c. (a) Radiograph in a female neonate shows that the umbilical venous catheter (large arrow) is deviated to the right. Note that the umbilical arterial catheter (small arrow) also is deviated to the right. The tip of the nasogastric tube is in the left part of the abdomen within the expected anatomic location of the stomach, with prominent apex rightward convexity of the intrathoracic portion. (b) Radiograph in a male neonate shows that the umbilical venous catheter (large arrow) is positioned within the right portal vein. The umbilical arterial catheter has the expected course, with the tip at the T10 level. Note that the tip (small arrow) of the nasogastric tube is in the left side of the abdomen, within the expected anatomic location of the stomach.
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In eight of the 10 patients with a right-sided CDH and an umbilical venous catheter, the catheter demonstrated a rightward shift (Fig 4) with various tip positions. All eight of these patients had liver within the hernia. In the other two patients, the catheter demonstrated mild rightward convexity and leftward displacement, respectively.
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Figure 4. Frontal radiograph obtained in a male neonate with right-sided CDH on the 1st day of life shows rightward deviation of the umbilical venous catheter (large arrow). Note that the nasogastric tube (small arrow) has apex leftward convexity.
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Thirty-nine patients with CDH had an umbilical arterial catheter. The hernia was on the left in 28 of these patients and on the right in 11. The catheters in all but two patients demonstrated the expected anatomic course. In the two patients, both of whom had a large left-sided CDH, the umbilical arterial catheter was deviated to the right (Fig 3a).
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DISCUSSION
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Most children who have CDH during the neonatal period, usually at birth, have respiratory distress and require intensive care. One of the primary roles of radiography in the neonatal intensive care unit is to help evaluate the position of the support apparatus (eg, endotracheal tubes, nasogastric tubes, and umbilical arterial and venous catheters) (1–4). Deviation of the course or tip position from the normal expected location at radiography is often associated with the need for catheter or tube repositioning (1,3). The expected anatomic course of such support apparatus has been well established in otherwise healthy neonates (1–4). In this study, we demonstrated several patterns of deviation in the anatomic location of support apparatus that may be encountered in neonates with CDH. When these deviations are encountered, they should not be misinterpreted as tube malposition.
It is not surprising that the courses of the umbilical venous catheters and nasogastric tubes were affected more often than were those of the umbilical arterial catheters. The stomach and liver, which help determine the position of umbilical venous catheters and nasogastric tubes, are often in an abnormal position in patients with CDH. Conversely, the descending aorta, which helps determine the position of umbilical arterial catheters, is retroperitoneal and relatively immobile. In our study, the course of umbilical arterial catheters usually was not affected, except in the presence of a large, left-sided CDH that caused the descending aorta to deviate to the right.
With right-sided hernias, it is common for umbilical venous catheters to be deviated to the right. With left-sided hernias, umbilical venous catheters usually are not in the expected anatomic location and often demonstrate either rightward deviation, prominent apex leftward angulation, or tip position within the portal venous system. The increased frequency of portal venous cannulation may be related to the distortion of the connection between the umbilical vein, left portal vein, and hepatic veins that is caused by the repositioned liver and mediastinum. This distortion may cause the catheter to deflect into the portal venous system rather than pass through into the hepatic veins.
The findings of CDH at chest radiography are well documented (5–8), and the diagnosis is often obvious on the basis of these findings. A nonaerated CDH, however, can appear as a solid mass, and an aerated hernia may be difficult to differentiate from other causes of congenital cystic lung masses (eg, congenital cystic adenomatoid malformations) (9). In cases in which the diagnosis of CDH is not clear, the patterns of the support apparatus can be useful for supporting the diagnosis. In one previous study (10), the investigators determined that the position of the umbilical vascular catheters was helpful for diagnosing CDH in three patients before air appeared within the hernias. Obviously, the position of the tip of a nasogastric tube within the left hemithorax is indicative of a CDH. However, the presence of a nasogastric tube with its tip positioned or lodged at the expected location of the esophagogastric junction and certain patterns of deviation of umbilical venous catheters also are indicative of a CDH. It is likely that the increased angulation between the esophagus and the stomach, which is caused by elevation of the stomach into a left-sided CDH, results in increased resistance to the nasogastric tube being advanced beyond that point.
The patterns of deviation of support apparatus in neonates with CDH can also be indicative of hernia contents—more specifically, whether the stomach and/or liver is within the hernia. The presence of the stomach within the hernia has been advocated as an important predictor of prognosis in these patients (5,8,11,12). In one previous article (11), the investigators noted that the mortality rate was 6.2% when the stomach was within the abdomen and 58.8% when the stomach was in the thorax. In addition, other investigators (5,8,12) have noted a statistically significant relationship but less dramatic correlation between gastric herniation and a high mortality rate.
In this series, the presence of the tip of the nasogastric tube at either the esophagogastric junction or within the hemithorax was highly predictive of the stomach being present within a left-sided CDH. Likewise, rightward deviation of an umbilical venous catheter in the presence of a right-sided CDH was highly predictive of the liver being within the CDH. The results of other studies (13,14) have shown that changes in the course of the umbilical vein and ductus venosus, as depicted on prenatal color Doppler studies of fetuses with left-sided CDH, are predictive of liver being present within the hernia. The relationship between right-sided CDH and an absent ductus venosus with an anomalous umbilical vein has been reported (15). In our study, none of the patients in whom surgery or autopsy was performed had evidence of anomalous vessels.
One limitation of this study with regard to the relationship between support apparatus position and hernia contents was that for many of the patients, there was no surgical or autopsy documentation of the hernia contents. Imaging findings were used as the standard of documentation in these patients.
In summary, in neonates with left-sided CDH, the tip of a nasogastric tube most commonly is positioned either in the left hemithorax or at the esophagogastric junction. A normally positioned nasogastric tube is associated with the absence of the stomach within the hernia. Umbilical venous catheters often show apex leftward convexity. In neonates with right-sided CDH, nasogastric tubes almost always have leftward deviation, and umbilical venous catheters usually are deviated to the right. Umbilical arterial catheters typically do not deviate from the expected pattern in patients with CDH. In conclusion, nasogastric and umbilical venous catheters demonstrate several patterns of deviation in neonates with CDH, and knowledge of these variations may be helpful for supporting the diagnosis of CDH in unclear cases and thus avoiding unnecessary apparatus adjustments, and for predicting hernia contents.
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FOOTNOTES
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2 Current address: Department of Radiology, University of Tennessee Medical Center, Knoxville. 
Abbreviation: CDH = congenital diaphragmatic hernia
Author contributions: Guarantor of integrity of entire study, L.F.D.; study concepts and design, M.S., L.F.D.; definition of intellectual content, all authors; literature research, M.S., L.F.D.; clinical studies, all authors; data acquisition, all authors; data analysis, M.S., L.F.D.; manuscript preparation, M.S., L.F.D.; manuscript editing and review, all authors.
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ABSTRACT
INTRODUCTION
