Nasogastric tube migration through a distal esophageal perforation into the pleural space in a nonagenarian woman with recurrent empyema: a case report
This case report describes a rare instance of a nasogastric tube migrating through a distal esophageal perforation into the right pleural space of a 90-year-old woman, causing recurrent empyema that was successfully managed with urgent surgical repair and decortication, underscoring the critical need for verifying tube placement and promptly addressing gastrointestinal-pleural communications.
Original paper licensed under CC BY 4.0 (https://creativecommons.org/licenses/by/4.0/). This is an AI-generated explanation of the paper below. It is not written or endorsed by the authors. For technical accuracy, refer to the original paper. Read full disclaimer
In the critical care units of hospitals around the world, a simple plastic tube is a lifeline for patients who cannot eat on their own. This tube, known as a nasogastric tube, is threaded through the nose, down the throat, and into the stomach to deliver liquid food and medicine. Because the tube passes through the neck and chest, close to the lungs, doctors must be certain it has reached the stomach and not wandered into the airways or the space surrounding the lungs. If the tube is placed incorrectly and food is pumped through it, that nourishment can spill into the chest cavity, causing severe infection and breathing trouble. While medical teams have strict rules for checking the tube's position, mistakes can still happen, especially in elderly patients who may have difficulty swallowing or altered consciousness. The consequences of such an error can be life-threatening, turning a routine procedure into a complex medical crisis.
This story begins with a ninety-year-old woman who was transferred to a hospital in Riyadh, Saudi Arabia, in October 2023. She had a history of high blood pressure, diabetes, kidney disease, and a previous stroke that left her with severe neurological impairment. She was bedridden, had a tracheostomy to help her breathe, and relied on a machine to ventilate her lungs. She also had a nasogastric tube that had been inserted at a different hospital the month before. When she arrived at the new facility, she was stable but had a serious infection in the space around her right lung, known as an empyema. A tube draining fluid from her chest was removing pus, but the medical team noticed something strange about the fluid. It looked and smelled like the liquid formula used for feeding, suggesting that the feeding tube was not in her stomach at all, but had somehow leaked into her chest.
A scan of her chest confirmed the terrifying reality. The tip of the feeding tube had pierced a hole in the lower part of her esophagus, the tube that carries food from the throat to the stomach. Instead of stopping in the stomach, the tube had pushed through the wall of the esophagus and migrated directly into the right side of her chest cavity. This breach allowed the liquid food to spill out of the digestive system and into the space surrounding the lung, creating a direct connection between the gut and the chest. The infection was severe, and the patient required immediate, coordinated action from a team of specialists, including intensive care doctors and surgeons.
On October 14, the patient underwent urgent surgery. The surgeons opened her chest to repair the hole in the esophagus and to clean out the infected fluid and scar tissue that had built up around her lung. They also placed a new drain to help remove any remaining fluid. After the operation, she was kept without any food or drink by mouth and received all her nutrition through an intravenous line. Her medical team treated her infection with powerful antibiotics and antifungal medications. A few days later, they tried to check if the hole in her esophagus had healed by having her swallow a special liquid that shows up on X-rays, but the results were unclear. A follow-up scan raised concerns that the liquid might still be leaking. To be absolutely sure, the doctors used a camera to look directly inside her throat and esophagus. This examination showed no active leak, confirming that the repair had held.
With the safety of the repair confirmed, the team slowly restarted her feeding through the tube, and she tolerated it well. By the end of October, she was stable and able to receive nutrition through her nose again, though she remained dependent on the breathing machine through her tracheostomy due to her pre-existing neurological condition. The case highlights a critical lesson for medical care: when fluid draining from a chest tube looks like liquid food, it is a sign that something is dangerously wrong. In this instance, the unusual appearance of the drainage led to a diagnosis that saved the patient's life. The doctors concluded that while placing a feeding tube is a common procedure, verifying its position with a scan before use is essential, especially in vulnerable patients. When a tube ends up in the wrong place, it can cause catastrophic contamination, and fixing it requires quick, decisive surgical intervention to clean the infection and seal the breach.
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