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Gastrointestinal Imaging |
1 From the Department of Radiology, Hospital of the University of Pennsylvania, 3400 Spruce St, Philadelphia, PA 19104. Received May 23, 2001; revision requested June 29; revision received September 6; accepted October 10. Address correspondence to M.S.L. (e-mail: levine@rad.upenn.edu).
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ABSTRACT |
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 TOP ABSTRACT INTRODUCTIONMATERIALS AND METHODSRESULTS DISCUSSIONREFERENCES |
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MATERIALS AND METHODS: Radiology database review revealed that 280 studies of the J tube or of the small bowel with water-soluble contrast material and/or barium sulfate were performed in patients during 10 years. Review of the radiologic reports revealed abnormalities related to the placement of tubes in 105 (38%) cases. Images were reviewed to determine abnormalities in these 105 cases. Radiologic, medical, and surgical records were also reviewed to determine the clinical course and any subsequent interventions.
RESULTS: One or more complications were detected in 40 (14%) of 280 cases: small-bowel obstruction in 17 (6%) cases, nonobstructive small-bowel narrowing in six (2%), extraluminal tracks or collections in seven (2%), extravasation of contrast material to the skin in 11 (4%), jejunal hematomas in five (2%), and intussusceptions in four (1%). Mechanical problems related to the tube were detected in 52 (19%) cases, including coiling, kinking, or knotting of the tube in 38 (14%), malpositioning in five (2%), retrograde flow in four (1%), occlusion in four (1%), and a hole in one (<1%). Focal thickening of small-bowel folds was detected in 24 (9%) cases.
CONCLUSION: Radiographs in 280 patients with J tubes revealed one or more complications that resulted from tube placement (40 [14%] cases), mechanical problems related to location or function of the tube (52 [19%] cases), and development of focally thickened small-bowel folds (24 [9%] cases).
© RSNA, 2002
Index terms: Catheters and catheterization, complications, 74.723, 74.73 • Intestines, injuries, 74.458 • Jejunostomy, 741.458 • Nutrition
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INTRODUCTION |
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TOPABSTRACTINTRODUCTIONMATERIALS AND METHODSRESULTS DISCUSSIONREFERENCES |
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Radiography of the J tube and of the small bowel with water-soluble contrast material (diatrizoate meglumine and diatrizoate sodium solution, Gastroview; Mallinckrodt, St Louis, Mo) or barium sulfate often is performed to assess the location and function of the tube and to evaluate the small bowel for possible complications. To our knowledge, however, few data about the radiographic findings associated with these complications are available in the radiologic literature. The purpose of our investigation, therefore, was to determine the frequency and nature of abnormalities observed on radiographs of J tubes after placement.
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MATERIALS AND METHODS |
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TOPABSTRACTINTRODUCTIONMATERIALS AND METHODSRESULTS DISCUSSIONREFERENCES |
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The J tubes that were placed with surgery were situated by using a variation of an intramural or subserosal track in the jejunum. These tubes were advanced into the lumen either blindly or with direct palpation, depending on the preference of the surgeon. The segment of jejunum containing the J tube was then fixed to the anterior abdominal wall (10). Interventional radiologists placed other J tubes percutaneously with fluoroscopic guidance after insufflation of air into the small bowel through a nasoenteric tube. Direct puncture of the jejunum was performed, and water-soluble contrast material was injected into the lumen to confirm the location of the small bowel. An anchor suture was then used to fix the jejunal loop to the anterior abdominal wall. The anterior abdominal wall track subsequently was dilated, and a locking-loop catheter was placed intraluminally (3).
In all 105 cases, a radiology resident or one of four attending gastrointestinal radiologists (M.S.L., S.E.R., I.L., H.H.) performed the radiographic study of the J tube by injecting water-soluble contrast material into the tube. In eight of these cases, a repeat study of the tube was performed with barium sulfate after extravasation was excluded with water-soluble contrast material. In 30 cases, evaluation of the small bowel with oral administration of contrast material (n = 18) or with injection of contrast material through a gastrostomy tube (n = 7) or nasogastric tube (n = 5) also was performed.
Radiographs in these 105 cases were reviewed and analyzed by two authors (L.R.C., M.S.L.) together by consensus to further characterize the nature of the abnormalities observed on radiographs after placement of J tubes. These abnormalities included complications that resulted from placement of the tube (ie, small-bowel obstruction, nonobstructive small-bowel narrowing, sealed-off extraluminal tracks or collections, extravasation of contrast material to the skin, jejunal hematomas, small-bowel intussusception, and pneumatosis cystoides intestinalis), mechanical problems related to the location or function of the tube (ie, coiling, kinking, knotting, malpositioning, occlusion, or disruption of the J tube and retrograde flow of contrast material), and the development of focally thickened small-bowel folds as an isolated finding at or just distal to the intraluminal end of the tube. In patients in whom these small-bowel folds developed, the degree of fold thickening was considered to be marked if the folds were greater than 5 mm wide and mild to moderate if the folds were less than 5 mm wide.
The interval between placement of the tubes and detection of these abnormalities was also noted. Radiologic, medical, and surgical records were subsequently reviewed (L.R.C.) to determine the clinical course, including any subsequent interventions, in these patients.
Approval was obtained from the internal review board at our institution for all aspects of this retrospective study; informed consent was not required by our internal review board.
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RESULTS |
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TOPABSTRACTINTRODUCTIONMATERIALS AND METHODSRESULTS DISCUSSIONREFERENCES |
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Small-bowel obstruction.—Small-bowel obstruction was identified at or near the site of entry of the J tube into the jejunum in 17 (6%) of 280 cases. In 11 of these cases, patients underwent follow-through studies (barium sulfate was administered orally in nine and through a nasogastric tube in two) and studies through the J tube. In all cases, radiographs revealed a focal transition at the site of obstruction with varying degrees of angulation or tethering at the site of narrowing, a dilated small bowel proximally, and a nondilated small bowel distally (Fig 1).
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Nonobstructive small-bowel narrowing.—Nonobstructive narrowing of the small bowel was identified at or near the site of entry of the J tube into the jejunum in six (2%) of 280 cases. In all cases, the narrowing was associated with varying degrees of angulation or tethering and was presumed to be caused by the tube itself or by developing adhesions in this region. This complication occurred later in the course of enteral feeding (an average of 309 days after placement of the J tube) than did other complications. In two (33%) of six cases, nonobstructive small-bowel narrowing resulted in failure of enteral feeding. Both cases required surgical removal of the J tube, with small-bowel resection in one and lysis of adhesions in the other.
Sealed-off extraluminal tracks or collections.—Sealed-off extraluminal tracks (n = 4) and/or collections (n = 4) in the peritoneal space were identified in seven (2%) of 280 cases (Fig 2). This finding was associated with varying degrees of small-bowel obstruction in five of the seven cases and with nonobstructive narrowing of the small bowel in two. Interruption of enteral feeding was necessary in all cases. Four (57%) of seven patients required fluoroscopic guidance for manipulation and replacement of the tube, and two (29%) required small-bowel resection.
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Coiling, kinking, or knotting of the J tube.—Radiographic study findings revealed coiling (n = 22) (Fig 4), kinking (n = 15), or knotting (n = 1) of the end of the J tube in 38 (14%) of 280 cases. Findings in the studies showed resistance to antegrade flow of contrast material in 27 cases and small-bowel obstruction at the site of the abnormality related to placement of the J tube in three. In eight cases, there was normal antegrade flow of contrast material without evidence of obstruction. In 23 (61%) of these 38 cases, the J tube was repositioned with fluoroscopic guidance to eliminate coiling or kinking of the J tube. In 15 cases (39%), enteral feeding was continued without repositioning of the tube.
Malpositioning of the J tube.—In five (2%) of 280 cases, injection of contrast material through the J tube revealed a malpositioned tube, with its tip in the duodenum in three (including the third portion of the duodenum in two and the duodenal bulb in one) (Fig 7) and in a fistulous track in two. In four of these five cases, the J tube was repositioned with fluoroscopic guidance prior to resumption of enteral feeding. In one case, the tube was left in the third portion of the duodenum, and enteral feeding was continued without difficulty.
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Occlusion of the J tube or hole in the J tube.—In four (1%) of 280 cases, injection of contrast material into the J tube revealed occlusion of the tube. In one (<1%) of 280 cases, a hole was detected in the tube outside the abdomen, with focal extravasation of contrast material from the tube. In all five cases, the tube was subsequently replaced with fluoroscopic guidance.
Thickened small-bowel folds.—Thickened small-bowel folds were identified as an isolated finding in a focal segment of the small bowel at or just distal to the intraluminal end of the J tube in 24 (9%) of 280 cases at radiographic study in patients in whom J tubes were placed. The fold thickening was characterized as mild to moderate in 21 cases (Fig 8) and as marked in three (Fig 9). Clinical follow-up findings in these patients revealed an uncomplicated clinical course, with successful continuation of enteral feeding in all cases.
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DISCUSSION |
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TOPABSTRACTINTRODUCTIONMATERIALS AND METHODSRESULTS DISCUSSIONREFERENCES |
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Despite the attractiveness of the enteral route for maintaining nutrition, complications have been reported (11,13,17) in 2%–12% of patients in whom J tubes have been placed. The most common complications included local skin infections, gastrointestinal symptoms (eg, nausea, vomiting, diarrhea, and abdominal bloating), and metabolic abnormalities (7–9,11–13,18–23). The use of J tubes for enteral feeding may even result in fatal complications, such as aspiration pneumonia, peritonitis, and, rarely, small-bowel necrosis (14,16,18,19,24–26). Careful monitoring of patients in whom J tubes have been placed, therefore, is essential to detect these complications at the earliest possible stage.
With greater use of J tubes, radiologists increasingly have been asked to perform radiographic studies of the J tube and of the small bowel with water-soluble contrast material or barium sulfate to confirm the location and patency of the J tube before initiating tube feeding. These studies also may be performed because a patient may be suspected of having complications related to the tube or mechanical problems associated with enteral feeding. Radiologists, therefore, need to be aware of the abnormalities related to placement of the J tube and of the abnormalities of the small bowel seen on radiographs in these patients. Apart from descriptions of the interventional techniques used for placement of catheters (3,9,27), however, little has been written in the radiologic literature about the radiographic evaluation of J tubes.
In our study, one or more complications were detected in 40 (14%) of 280 cases at radiographic examination in patients in whom J tubes were placed. The most serious complications included small-bowel obstruction, nonobstructive small-bowel narrowing, and extraluminal tracks or collections. Other complications not previously reported included jejunal hematomas and focal intussusception of the small bowel at the site of the J tube. In our series, the complication rate was higher than the complication rates reported in the literature and was presumably related to selection bias, since many of our patients underwent radiographic examinations only because they were suspected of having complications.
Small-bowel obstruction caused by postsurgical adhesions related to the J tube was a particularly ominous finding on radiographs. This finding resulted in failure of enteral feeding in 10 (59%) of 17 cases and necessitated surgery, with lysis of adhesions or small-bowel resection, in five (29%). Small-bowel obstruction may be better evaluated with follow-through studies of the small bowel than with studies of the J tube because of the potential problem of injecting barium sulfate or water-soluble contrast material into the lumen of the bowel at the tip of the J tube distal to the site of obstruction. Nonobstructive small-bowel narrowing caused by the tube itself or by developing adhesions also was a serious problem and resulted in failure of enteral feeding and the subsequent need for surgical intervention in two (33%) of six cases. However, this group of patients had fewer abdominal symptoms, so nonobstructive small-bowel narrowing was detected much later in the course of enteral feeding than was small-bowel obstruction.
The presence of extraluminal tracks and collections was also an ominous finding on radiographs; because of this finding, replacement of the tube was necessary in four (57%) of seven cases and small-bowel resection was necessary in two (29%). In contrast, extravasation of contrast material around the J tube to the skin was a less serious complication; adjustment of tube feeding or manipulation of the tube with fluoroscopic guidance resulted in successful continuation of enteral feeding in nine (82%) of 11 cases.
Less common complications included jejunal hematomas and intussusception, which were detected in nine (3%) of 280 cases. These complications tended to occur early in the course of enteral feeding as transient findings that were not associated with feeding tube failure. The hematomas presumably resulted from injury of the bowel wall at the time of tube placement, whereas intussusception resulted from an intraluminal effect of the J tube itself, which appeared to serve as the lead point for intussusception in these cases. Whatever the pathogenesis, radiologists should recognize that both hematomas and small-bowel intussusception usually occur as self-limited findings that do not interfere with enteral feeding.
One patient in our series developed benign pneumatosis cystoides intestinalis that involved several loops of proximal jejunum adjacent to the J tube. This is a rare complication of placement of the J tube that has been reported in less than 1% of cases (8,20,25). In our investigation and in those of others (8,28–30), pneumatosis cystoides intestinalis was detected within 2 weeks of placement of the tube. It has been postulated that this finding results from increased intraluminal pressure caused by injection of air through the catheter or by an associated intestinal ileus, with subsequent dissection of gas into the bowel wall by means of a mucosal defect created by the catheter (20,29). In the past, pneumatosis cystoides intestinalis associated with placement of J tubes resolved by means of conservative therapy, with temporary cessation of enteral feeding (10,20,25,28–30). Nevertheless, this benign form of pneumatosis cystoides intestinalis must be differentiated from intramural gas in patients with bowel ischemia and necrosis, an exceedingly rare complication of placement of J tubes (10,14,26).
Enteral feeding after placement of the J tube may also be compromised by malfunction of the tube (11,31). In our study, mechanical problems related to the location or function of the tube were detected in 52 (19%) of 280 cases at radiographic examination in patients in whom J tubes were placed. The most common problem was coiling, kinking, or knotting of the end of the tube, which occurred in 38 (14%) of 280 cases. This problem is found more frequently with surgically placed J tubes than with those placed fluoroscopically, because surgically placed tubes are advanced distally in the bowel without the advantage of direct fluoroscopic visualization (2,7,32).
A much less common problem was malpositioning of the tip of the tube in the duodenum or retrograde flow of contrast material into the duodenum, the stomach, or the esophagus, which occurred in nine (3%) of 280 cases. J tubes are more likely to be malpositioned in the duodenum when they are placed endoscopically, because of the technique of placement and the tendency for these tubes to migrate proximally (4,33,34). When any of these problems were encountered, successful continuation of enteral feeding was usually possible after fluoroscopic manipulation or replacement of the J tube by interventional radiologists.
Thickened small-bowel folds were identified as an isolated finding in a focal segment of small bowel at or just distal to the intraluminal end of the J tube in 24 (9%) of 280 cases. Focal thickening of folds, therefore, represents a common finding in the small bowel after placement of J tubes and most likely results from either irritation of the bowel by the tube itself or from fluid shifts that occur when hyperosmolar formulas are administered through the tube (1,10,13). Whatever the explanation, all these patients had an uncomplicated clinical course, with successful continuation of enteral feeding. Thus, focal thickening of small-bowel folds at or near the end of the J tube should be recognized as an innocuous finding on radiographs after placement.
In summary, radiographs in 280 cases in patients in whom J tubes were placed for enteral nutrition revealed one or more complications that resulted from tube placement (40 [14%] cases), mechanical problems related to the location or function of the tube (52 [19%] cases), and development of focally thickened small-bowel folds (24 [9%] cases). Depending on the nature of the abnormality, various treatment options included continued enteral feeding, temporary adjustment or withholding of enteral feeding, manipulation or replacement of the J tube, or surgery.
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FOOTNOTES |
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Author contributions: Guarantor of integrity of entire study, M.S.L.; study concepts and design, L.R.C., M.S.L.; literature research, L.R.C.; clinical studies, M.S.L., S.E.R., I.L., H.H.; data acquisition and analysis/interpretation, L.R.C., S.A., M.S.L.; manuscript preparation and definition of intellectual content, L.R.C., M.S.L.; manuscript editing, revision/review, and final version approval, L.R.C., M.S.L., S.E.R., I.L., H.H.
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REFERENCES |
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TOPABSTRACTINTRODUCTIONMATERIALS AND METHODSRESULTS DISCUSSIONREFERENCES |
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This article has been cited by other articles:
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  M. M. Munden, J. F. Bruzzi, B. D. Coley, and R. F. Munden Sonography of Pediatric Small-Bowel Intussusception: Differentiating Surgical from Nonsurgical Cases Am. J. Roentgenol., January 1, 2007; 188(1): 275 - 279. [Abstract] [Full Text] [PDF]
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 A M Connors and S P Blake Multiple-choice questionnaire: general Imaging, October 1, 2002; 14(5): 428 - 437. [Full Text] [PDF]
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