Monday, November 23, 2015

Pull Percutaneous Gastrostomy Tube

A prior post detailed how to place a conventional gastrostomy tube as an interventional radiologist. However, a variant based on the approach endoscopists use is the pull percutaneous gastrostomy tube. Other names for this technique are the mushroom or Ponsky gastrostomy tube. The steps are as follows:

  1. Verify an appropriate window for the gastrostomy tube on pre-procedure imaging. In particular, make sure that the transverse colon does not lie between the anterior abdominal wall and the stomach. Alternatively, use ultrasound to check for liver margin and a rectal enema to opacify the transverse colon. 
  2. Check if the patient has a nasogastric tube. If not, using anesthetic gel and a glidewire, a Kumpe catheter can be fluoroscopically guided into the stomach. Have an assistant use the tube to insufflate the stomach. Point the Kumpe straight back with the tip facing down, then flip it 180 degrees to lead away from the trachea.
  3. Once the stomach is sufficiently inflated, anesthetize the skin. A good location is midway along the greater curve as the passes will aim towards the fundus.
  4. Use a 19G Chiba needle to access the stomach. Once intraluminal position confirmed, direct the needle posteriomedially towards the NG tube (ideally, nudge it under fluoro). 
  5. Leading with an 0.035” Amplatz, direct the wire retrograde up the esophagus. 
  6. An assistant will retrieve the wire from the mouth. Once outside, attach a snare (comes in kit) to the back end of the wire near the stomach and pull the snare through to the mouth. 
  7. Release the snare from the wire, then tie a hitch knot to the gastrostomy tube. 
  8. Pull the gastrostomy tube antegrade through the esophagus into the stomach. 
  9. Store a fluoro image with contrast injection to verify location.

Be mindful that a near absolute contraindication to this procedure is any patient with skull base, head and neck, or esophageal cancer / obstruction.

There are several benefits to placing a primary gastrostomy tube in this manner:
  • No T-Tacks to cut
  • 20 Fr instead of 14 Fr, so decreased risk of clogging
  • More durable
  • No pigtail within the gastric lumen, so less concern for gastric outlet obstruction
  • Generally less messy because no dilatation needed, and only one stick into the abdominal wall
Bard's Version of the Pull G-Tube (Copyright Bard)

Monday, June 22, 2015


A lymphangiogram is an uncommon procedure that can be performed by interventional radiologists, typically to identify and potentially treat the source of a chylous leak.

Pre Procedure

  • Indications: Thoracic duct injury, usually from surgery, causing chylous effusion / chylothorax, or recurrent chylous ascites
  • Surgical management (direct fix of the leak intraoperatively if visualized) and medical management should be optimized first. 
  • Specifically, the patient should be on a low fat / medium chain triglyceride diet. Long chain triglycerides are absorbed by the lymphatics, which leads to extra lymph production. Medium chain triglycerides however are absorbed by the portal veins, reducing the production of lymph.  


  • Transpedal approach: prep the feet
  • Inject 50/50 mix of isosulfan blue and lidocaine into the webbing between toes and wait 10-15 minutes for dye to be picked up by lymphatics
  • Make incision parallel to lymphatic
  • Strip away fat/tissue parallel to lymphatic
  • Insert backing (cardboard/plastic) underneath lymphatic
  • Insert 30 gauge needle into lymphatic and inject 100% lidocaine
    • Bubble test: watch to see if air goes into lymphatics, or if it fizzes
  • Take serial x-rays of lower extremities and abdomen to see lymphatics and eventually cysterna chyli fill
  • Once filled, can insert 21 gauge needle directly into cisterna chyli and perform embolization, usually with coils and/or N-butyl cyanoacrylate glue

Post Procedure

  • Evaluate for recurrent leak

Monday, June 15, 2015

A Simplified Approach To Spinal Masses

Spinal cord masses can be confusing at times, especially if not encountered routinely. While it may be difficult to arrive at a specific diagnosis, a narrowed differential can often be very helpful to the referring clinician. Clinical history is also quite useful at narrowing the differential.

The first question to ask is where exactly is the tumor located within the spinal canal. The broad categories are: intramedullary, intradural-extramedullary, and extradural. An intramedullary mass will be centered within the substance of the spinal cord itself, which has been described as the claw sign. An intradural-extramedullary mass will form a meniscus with the cord and push it away. An extradural mass will be outside the thecal sac. Vertebral body or clear epidural involvement suggests an extradural location. In cases where the distinction is difficult, assess the cord above and below the mass.

Once that determination has been made, the chart below can help generate a differential by focusing on both the imaging characteristics and clinical context:

The chart is not comprehensive, but it does list the most common primary masses to be found within those locations within the spine. As always, metastases are a consideration in any of these locations. Making the distinction can be challenging at times, especially when the mass is large and distorts normal structures.


Monday, June 8, 2015

Leptomeningeal FLAIR Hyperintensity Differential Diagnosis

Hyper intensity in the subarachnoid space can have a wide range of causes. The finding may be subtle to detect at times. However, identifying it can be crucial in altering a patient's management. The mnemonic FLAIR can be used to recall the common causes of this finding:

FFiO2 highNo contrast enhancement
LLeptomeningeal spread of tumorGEMCLOG: glioblastoma, ependymoma, medulloblastoma, choroid plexus tumor, lymphoma, oligodendroglioma, germinoma
AAneurysmal bleedNo contrast enhancement
IInfection (meningitis)
RpRopofolNo contrast enhancement, may also be due to increased oxygen

Monday, June 1, 2015

Dilated Small Bowel Differential Diagnosis

A common finding in patients with abdominal pain is dilated loops of small bowel. Dilated loops may be noted on plain X-ray, fluoroscopic studies, or CT. The first step to forming a focused differential diagnosis is determining whether the folds are thin, thick (> 3 mm), or thick and nodular.

If the folds are thin, the mnemonic MISS can be used to recall the common diagnoses:

MMechanical obstructionDue to intraluminal impaction (high fiber foods), adhesions post-operatively, or a mass
IIleusPost-operatively, medications
Systemic sclerosis due to deposition of collagen
Sacculations of anti-mesenteric border
Hidebound bowel (unchanging on dynamic studies)
SSprueVillous atrophy and crypt hypertrophy → chronic fluid overload → ‘congestive gut overload’ → featureless mucosal pattern proximally in small bowel = reversal of jejunal / ileal fold pattern

Moulage sign: moulage means casted or molded structure; the jejunum appears a cast of itself due to featureless appearance because of lack of mucosal folds

Small Bowel Obstruction
Source: Radiology Assistant

If there is segmental thickening of the folds, think of the three Is: ischemia, infection, or idiopathic. Diffuse fold thickening is usually due to systemic processes such as venous congestion or cirrhosis.

Nodular fold thickening is usually due to infiltrative processes of the bowel wall. Common etiologies include Crohn disease, infection, lymphoma, metastases, and Whipple disease.

If the dilatation is thick walled, check out the differential diagnosis for small bowel aneurysmal dilatation.

If you want to learn more about GI imaging, specifically fluoroscopy, the Mayo Clinic Gastrointestinal Imaging book is a wonderful reference with over 500 images: