title: Undetected oesophageal perforation and feeding-tube misplacement.
abstract: This is a case report of an electromagnetically (EM)-guided Cortrak feeding tube that perforated the lower oesophagus and was not detected by the EM trace or by plain X-ray. Misplacement was diagnosed from computed tomography (CT) following injection of radio-contrast medium down the tube. Recommendations are offered for use of the EM trace in patients at high risk of oesophageal perforation.
authors.affiliation: Research Dietitian, Department of Nutrition and Dietetics, Southmead Hospital, Bristol.
authors.forename: Stephen J
authors.initials: SJ
authors.lastname: Taylor
authors.forename: Catherine
authors.initials: C
authors.lastname: Ross
authors.forename: Timothy
authors.initials: T
authors.lastname: Hooper
mesh_terms: D004750:Enteral Nutrition / Q000009:adverse effects*; D004939:Esophageal Perforation / Q000209:etiology*; D006801:Humans; D007441:Intubation, Gastrointestinal / Q000009:adverse effects*
keywords: Cortrak; Misplacement; Nasogastric tube; Nasointestinal tube