Radiography (X-ray) Confirms G-Tube Placement
Every patient should undergo radiography to confirm proper position of a gastrostomy tube before feeding is initiated. 1
Why X-ray is the Gold Standard
X-ray remains the universally accepted "gold standard" for confirming gastrostomy tube position, as it directly visualizes the tube location and can detect misplacement in the lung, pleural cavity, or esophagus. 1, 2, 3
Bedside auscultation (the "whoosh test") is misleading and unreliable—inappropriate tube locations such as in the lung, pleural cavity after perforation, or coiled in the esophagus may be misinterpreted as proper position by auscultatory techniques. 1
Placement Guidance Methods (Not Confirmation)
While the question asks about confirmation, it's important to distinguish placement guidance from post-placement confirmation:
Endoscopic guidance is used during transoral G-tube placement (PEG tubes), where the endoscopist directly visualizes gastric puncture and tube positioning in real-time. 1
Fluoroscopic guidance is used during transabdominal G-tube placement, where the stomach is insufflated and the tube is placed under continuous X-ray visualization. 1
Both methods achieve >95% success rates, but these are placement techniques—post-placement radiographic confirmation is still standard practice. 1
Alternative Confirmation Methods (Limited Role)
Ultrasound has been studied but lacks sufficient accuracy as a single confirmation test:
Bedside abdominal ultrasound shows sensitivity of 99.8% but specificity of only 91.0% for nasogastric tubes, with 7.6% of examinations being inconclusive. 4
A 2024 Cochrane review concluded that ultrasound does not have sufficient accuracy as a single test to confirm gastric tube placement, though it may be useful when X-ray is unavailable. 5
Ultrasound sensitivity ranges from 0.96-0.98 for various injection methods, but evidence for specificity is very low due to small sample sizes and low misplacement incidence. 5
Critical Post-Placement Care
Once position is confirmed by X-ray:
The external bumper must be positioned approximately 1 cm or more from the abdominal wall to allow at least 5 mm of free movement, preventing pressure necrosis, buried bumper syndrome, and wound infection. 6
For balloon-type G-tubes, inflate exclusively with sterile water (not saline) in volumes of 5-10 ml, and verify weekly to prevent spontaneous deflation and tube displacement. 7
Common Pitfall
Never rely on auscultation alone—this method has led to fatal complications from feeding through misplaced tubes in the lung or esophagus. Always obtain radiographic confirmation before initiating feeding. 1, 2