Key findings and the importance of tangential views in gastrostomy tube evaluation: a rare case of a malpositioned gastrostomy tube within the anterior abdominal wall after surgical placement.

Gastrostomy tube placement is a commonly performed procedure that is generally well tolerated with limited complications. Despite its relatively low complication rate, early displacement or malpositioning of the gastrostomy tube is sometimes encountered. Expedited identification of malpositioning is paramount to avoid intraperitoneal feeds and resulting peritonitis, maturation of the wayward gastrostomy tube tract, as well as other comorbidities. Herein, we present a case of a pediatric patient with a malpositioned gastrostomy tube with the entirety of the tube located within the anterior abdominal wall subcutaneous soft tissues, a very rare location. A battery of radiographic studies was necessary to confirm the location of the malpositioned tube and to help guide surgical management in this complex patient. Importantly, this case highlights the necessity of tangential imaging planes, and the key findings needed to confirm a normally placed gastrostomy tube.