Medical Image of the Week: Dobhoff Placement in a Patient with Hiatal Hernia

Figure 1. Arrows designate tip of Dobhoff feeding tube (DHT). Panel A: Chest radiograph. DHT appears to follow the left main bronchus into the left lower lobe. Panel B: Abdominal view of DHT placement. Panel C: Chest CT showing degree of hiatal hernia and DHT in the intra-thoracic hernia. Panel D: Follow-up fluoroscopy imaging showing appropriately placed DHT in the duodenum.

A 79 year-old woman with a past medical history of obstructive sleep apnea, chronic obstructive pulmonary disease on home oxygen, obesity hypoventilation syndrome, hypertension, and anxiety presented with a 2 day history of altered mental status and symptoms consistent with a COPD exacerbation, including dyspnea and increased oxygen requirements. She was found to be hypercarbic and did not tolerate a trial of BiPAP due to her altered mentation. She was subsequently intubated. Due to an expected prolonged intubation period, plans for enteral access were made. A Dobhoff naso-duodenal feeding tube (DHT) was inserted. On chest radiograph and a concurrent abdominal radiograph, the DHT appeared to have been inserted into the left mainstem bronchus terminating in the left lower lobe (Figure 1A and 1B). The nursing staff removed and replaced the DHT resulting in a similar radiograph. A third placement was attempted with similar radiographic results. Therefore, a computed tomography (CT) scan of the chest was performed to evaluate tube placement. The CT of the chest showed a large hiatal hernia contained within thoracic cavity (Figure 1C). Upon chart review, previous radiographs mentioned hiatal hernia but it appeared that the degree of herniation had progressed. Fluoroscopy was used to confirm placement of the DHT beyond the herniated gastric contents into the duodenum (Figure 1D) and tube feeds were initiated.

Post-pyloric feeding tubes are often used in place of gastric feeding tubes under the assumption that the risk of aspiration in the intubated patient is reduced. Enteral nutrition is typically started within 36 hours of intubation as this has been shown to decrease mortality in intubated patients (1). There are contraindications to the use of nasogastric or nasoenteric feeding tubes, which include facial trauma, esophageal web, or recent esophagectomy. Hiatal hernias are not a contraindication to nasoenteric feeding tube placement, however, patients with unusual anatomy may benefit from placement under fluoroscopic or endoscopic visualization in order to ensure appropriate positioning (2).

Kawanjit K Sekhon, MD and Ryan Nahapetian, MD, MPH

Department of Internal Medicine

Division of Pulmonary, Allergy, Critical Care, and Sleep Medicine

University of Arizona, Tucson, AZ

References

1. Marik PE, Zaloga GP. Gastric versus post-pyloric feeding: a systematic review. Crit Care. 2003;7(3):R46-51. [CrossRef] [PubMed]

2. Hodin RA, Bordeianou L. Nasogastric and nasoenteric tubes. Uptodate.com. Oct 17, 2013. Dec 20, 2013. Available at: http://www.uptodate.com/contents/nasogastric-and-nasoenteric-tubes?source=machineLearning&search=hiatal+hernia+feeding+tube&selectedTitle=1%7E150&sectionRank=3&anchor=H522922014#H522922014 (requires subscription).

Reference as: Sekhon KK, Nahapetian R. Medical image of the week: Dobhoff placement in a patient with hiatal hernia. Southwest J Pulm Crit Care. 2015;10(1):49-50. doi: http://dx.doi.org/10.13175/swjpcc005-15 PDF

Medical Image of the Week: Hepatic Hydrothorax

Figure 1. Panel A: Chest x-ray showing right pleural effusion. Panel B: Coronal view of the thoracic CT scan in soft tissue windows showing right pleural effusion.

Figure 2. Nuclear scan after intraperitoneal injection of technetium 99mTc albumin aggregated (99mTc-MAA). After less than one hour most of the tracer migrated into the right hemithorax consistent with hepatic hydrothorax.

A 63 year-old woman, with known alcoholic liver cirrhosis, esophageal varices with history of banding presented to an outside hospital with progressive shortness of breath, and was found to have a large right transudative pleural effusion. The patient underwent 2 diagnostic and therapeutic thoracenteses within 3 days, removing 1100 ml and 1500 ml respectively. No ascites was present. At the time of admission the patient had recurrent right effusion (Figure 1). Abdominal ultrasound showed minimal free intrabdominal fluid and she had signs of third spacing on her lower extremities. The patient underwent intraperitoneal injection of Technetium 99mTc albumin aggregated (99mTc-MAA). After less than one hour most of the tracer migrated into the right hemithorax consistent with hepatic hydrothorax (Figure 2).

While the exact mechanism involved in the development of hepatic hydrothorax is incompletely understood, it probably results from the passage of ascitic fluid from the peritoneal into the pleural cavity through small diaphragmatic defects. These are typically < 1 cm (and may be microscopic) and are generally located in the tendinous portion of the diaphragm. The negative intrathoracic pressure generated during inspiration favors the passage of the fluid into the pleural space. Thus, patients may have only mild or clinically undetectable ascites.

Once the diagnosis is made treatment follows algorithms for treatment of refractory ascites and include salt and water restriction, diuretics, and other validated options for portal hypertension. Repeated thoracentesis and chest tube placement is discouraged.

Huthayfa Ateeli, Justin Lee, Irbaz Riaz, Meenal Misal

Department of Internal Medicine

University of Arizona

Tucson, AZ

References

1. Huang PM, Chang YL,Yang CY,Lee YC.The morphology of diaphragmatic defects in hepatic hydrothorax: thoracoscopic finding. J Thorac Cardiovasc Surg. 2005;130:141-5. [CrossRef] [PubMed]
2. Lieberman FL, Hidemura R, Peters RL, Reynolds TB. Pathogenesis and treatment of hydrothorax complicating cirrhosis with ascites. Ann Intern Med. 1966;64:341-51. [CrossRef] [PubMed]
3. Emerson PA, Davies JH. Hydrothorax complicating ascites. Lancet. 1955; 268:487-8. [CrossRef] [PubMed]
4. Mouroux J, Perrin C, Venissac N, Blaive B, Richelme H. Management of pleural effusion of cirrhotic origin. Chest. 1996;109:1093-6. [CrossRef] [PubMed]
5. Chen A, Ho YS, Tu YC, Tang HS, Cheng TC. Diaphragmatic defect as a cause of massive hydrothorax in cirrhosis of liver. J Clin Gastroenterol. 1988;10:663-6. [CrossRef] [PubMed] 

Reference as: Ateeli H, Lee J, Riaz I, Misal M. Medical image of the week: hepatic hydrothorax. Southwest J Pulm Crit Care. 2015;10(1):47-8. doi: http://dx.doi.org/10.13175/swjpcc004-15 PDF