Catastrophic complication of an electromagnetic placed postpyloric feeding tube.

To cite: Veltcamp Helbach M, Savelkoul C, Festen-Spanjer B, et al. BMJ Case Rep Published online: [please include Day Month Year] doi:10.1136/bcr-2016216738 DESCRIPTION An 83-year-old woman with Crohn’s disease presented at the emergency department with severe abdominal pain. Diagnostic colonoscopy confirmed sigmoid stenosis and pneumodilatation was performed. Post procedure the patient developed tachypnoea, tachycardia, fever and signs of an acute abdomen. Biochemistry showed hyperlactatemia as a sign of bowel hypoperfusion. The patient underwent a subtotal colectomy after a CT scan had revealed cecal rupture. She was admitted to the intensive care unit postoperatively. After extubation, a postpyloric feeding tube was inserted by electromagnetic sensorguided enteral access system (EMS-EAS, Cortrak) in three attempts for persistent gastric retention. Within a few hours however, she developed progressive respiratory failure. A chest X-ray (figure 1) showed right-sided endobronchial placement of the feeding tube, which was removed during intubation. Retrospectively, Cortrak tracing showed right-sided endobronchial positioning of the feeding tube as well (figure 2). The patient developed severe aspiration-induced lung injury with hypoxemic failure