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Gastric Tube Misplacement – from Enlightenment to Bed-side Solutions
Dr Kam CW
Emergency Physician in Community Practice
Good clinical practice requires proficient clinicians, well-equipped facilities, practical guidelines, and sound policies, supported by adequate healthcare investment. Minimally invasive care reduces patient suffering while maximizing outcomes. Clinicians must prioritize "Do no harm," but HALT syndrome risks (Hunger, Anger, Loneliness, Tiredness) must not be ignored. Structured training, team support, and open disclosure ensure quality performance and patient safety.
Plain CXR are the gold standard for confirming G-tube placement, but limitations persist, with 2.5% of cases failing to locate the tube tip. Thoracic or bowel shadows and thick abdominal walls can obscure the tip of G-tube. Novice clinician also lacks expertise with the Picture Archiving & Communications System (PACS) adjustments to highlight the faintly radio-opaque tube or the more radio-opaque line on the tube.
An adequate XR field of view from above C6 Vertebra (esophageal opening) to below diaphragm |
The G Tube crosses the Tracheal Carina or the Left Main Bronchus |
No Tube Coiling in the Chest Region |
The G Tube crosses the Diaphragm in midline at the T10 – 11 Level |
The G Tube Tip is evidently visible & located below the Left Hemi-diaphragm |
The G Tube Tip is at least 10 cm beyond the GOJ to ensure it is within the Gastric Body. |
Table 1: CXR signs to confirm G tube placement according to UK NHS and HK HA
Alternative bedside methods for G tube placement confirmation range from landmark with length-based criteria, auscultation, pH Test, PoCUS, manometry, capnography and upper endoscopy. Ultrasound has emerged as a practical, simple and non-invasive option especially in certain settings such as long-stay elderly hostels and busy hospital with tremendous X-ray delay.
Two-Point PoCUS | Transducers | Positive signs |
Neck – Esophageal Supra-sternal Transverse & Longitudinal | Linear Array Transducer (3–8 MHz) | G Tube – acoustic shadow hyperechogenic circle in transverse view (and Double Tract Sign) Hyper-echoic lines in longitudinal view Esophageal image easier to visualize than the gastric image |
Epigastric – Liver, Stomach Sub-xiphoid Transverse & Longitudinal | Phased Array or Curvilinear Transducer (2-4 MHz) | G Tube – hyperechogenic lines If acoustic shadow of a NGT not seen, 10 ml of air & 40 ml of NS mixture is injected through the G Tube to produce the dynamic fogging in B Mode USG and turbulent flow in color doppler Gastric Image more difficult to visualize than Eso Image owing to thicker abdominal wall, gastric air & other contents |
Table 2: USG confirmation signs for G tube placement
Two systematic reviews on USG show high sensitivity but unreliable specificity for G-tube placement confirmation. Meta-analysis found studies methods too heterogeneous with different methods and low incidence of malposition. While unsuitable as a universal standard, USG is accurate in ICU, A&E, paediatrics, and community nursing. Targeted training for long-term staff and quality assurance are vital to ensure safety and operator reliability. Guidelines incorporate conventional bedside procedures, USG and CXR in stages is a reasonable approach.
In summary, USG verification may be a feasible alternative if local policy provides a robust training and performance procedures with credentialling so as to maximize the patient outcome especially in under-resourced facilities.
BEST does not exist, always look for BETTER to improve the confirmation with the least pain & adverse effects!
Training Professionals, Helping Patients & Saving Lives are our Regular Mission!
*The full version of this article by the author is available to download here:
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