3086 “Knot” Your Average Nasogastric Tube

Abstract

INTRODUCTION: A nasogastric tube (NGT) is commonly used for gastric decompression or enteral nutrition. Placement is usually safely performed blindly with positioning confirmed on plain x-rays. NGT self-knotting is a rare complication that requires awareness as management may necessitate urgent endoscopy. CASE DESCRIPTION/METHODS: An 88-year-old man presented with nausea and vomiting, and was found to have a small bowel obstruction. He was managed conservatively with NGT placement for decompression. Due to low output, the tube required manipulation and repositioning. Upper GI series with small bowel follow was obtained for further evaluation with fluoroscopy images revealing a knotted NGT with the tip in the mid esophagus. Attempts were made at removal, but it could not be withdrawn or advanced due to patient discomfort. The patient underwent EGD which confirmed that the knotted NGT was lodged at the upper esophageal sphincter. The NGT was advanced under direct visualization to the stomach where the knotted end was snared. After cutting the proximal end exiting the nare, the knotted NGT was withdrawn endoscopically via the mouth. The patient eventually had resolution of his small bowel obstruction and was discharged. DISCUSSION: Though generally considered safe, NGTs are associated with a variety of complications occurring at a rate of 0.3% to 8%. These include aspiration, pneumothorax, tracheal misplacement, esophageal perforation, epistaxis, mediastinitis, and sinusitis. NGT function may be compromised by kinking, malpositioning, and occlusion of the tube. With the literature limited to few case reports and series, the true incidence of NGT self-knotting is unknown. NGT knotting increases risk for further complications such as respiratory difficulty and trauma to the nasopharynx, larynx, and esophagus, including tracheoesophageal perforation or fistulization. NGT knotting may occur from faulty insertion, altered anatomy, repetitive manipulation, narrow bore design, excessive length of tubing in the stomach, prolonged duration of placement, violent peristalsis, and softening of the tube at body temperature. NGT knotting should be considered in patients with any resistance upon attempts at removal. Plain radiographs or fluoroscopy can detect knotting. Various methods for removal of knotted NGTs have been described, generally involving cutting and removing the knotted part through the mouth with the help of direct laryngoscopy or EGD, as illustrated by this case. Watch the video: http://bit.ly/32EOwHS