This is a case report o f an electromagnetically (EM)-guided Cortrak feeding tube
that perforated the lower oesophagus and was not detected by the EM trace or
by plain X-ray. Misplacement was diagnosed from computed tomography (CT)
following injection o f radio-contrast medium down the tube. Recommendations are
offered for use o f the EM trace in patients at high risk o f oesophageal perforation.