A Rare Complication of an NG Tube: Intramural Esophageal Dissection

Abstract

Purpose: A 64 year old female with a history of multiple myeloma was admitted for a vertebral compression fracture and subsequently developed hospital acquired pneumonia. The patient was intubated and a Dobhoff nasogastric feeding tube was placed for respiratory support and enteral feedings, respectively. The patient developed persistent bleeding from the oropharynx. Evaluation by the ENT and pulmonary services did not identify a source of the patient's bleeding. An esophagogastroduodenoscopy demonstrated the NG tube dissecting the esophageal mucosa (Figure 1a) and exited 25 cm from the incisors (Figure 1b). The area was edematous and erythematous with active oozing at the area of esophageal wall dissection. The Dobhoff tube was gently removed and the area of hemorrhage appeared to cease oozing. Ultimately, sepsis syndrome ensued with multisystem organ failure. Given the extent of her comorbidities and declining overall status, the patient's family opted to withdraw care and the patient shortly passed away. Discussion: The placement of nasogastic tubes is a very common procedure in the hospital, and complications are rarely seen. The formation of an intramural esophageal dissection from a feeding tube can occur either through an area of existing breakage in the mucosa, such as an ulceration, or through forceful insertion of the tube through normal mucosa. Dissection and complete perforation are rare and can be fatal if not recognized in a timely fashion. Diagnosis of a perforation is typically made based on clinical presentation and history, pain in the neck or chest, signs of sepsis, leak seen on contrast studies and retropharyngeal air on CT scanning. When recognized early, dissection and small perforations may be treated conservatively with antibiotics, PPI therapy and fasting. More serious perforations may require surgical intervention. This case demonstrates a rare complication of a common hospital procedure, and the importance of early recognition of iatrogenic complications, even in seemingly benign procedures.Figure