• Jose C Flores, Jesús López-Herce, Itziar Sola, and Angel Carrillo.
• Sección de Cuidados Intensivos Pediátricos, Hospital Gregorio Marañón, Madrid, Spain.
• Nutrition. 2006 Feb 1; 22 (2): 209-12.

ObjectiveWe describe the case of a 2-mo-old infant who weighed 3.5 kg, had alveolar interstitial pneumopathy on mechanical ventilation, and developed a duodenal perforation due to a 6-Fr polyurethane transpyloric tube.Methods And ResultsAbdominal ultrasound showed the tube to be within the intestinal lumen. Due to this diagnostic error, nutrition was administered through the tube and the patient developed severe peritonitis. Laparotomy showed a perforation due to the transpyloric tube at the level of the union of the second and third portions of the duodenum. The perforation was sutured but the patient developed new intestinal perforations with severe progressive intestinal damage, leading to multiorgan failure and death.ConclusionsIf there is a clinical suspicion of intestinal perforation secondary to insertion of a transpyloric tube, the position of the tube must be confirmed by radiographic and echographic techniques. In case of doubt, the tube should be withdrawn and endoscopic or contrast radiographic evaluation must be performed.

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