An Unusual Suspect: Esophageal Mucosal Dissection: A Rare Complication of Nasogastric Intubation

Abstract

Introduction: Nasogastric intubation (NGT) is a frequently performed inpatient procedure for various indications. It is usually considered a safe procedure with only few reported serious complications. We report a case of patient who developed hematemesis after nasogastric intubation and was found to have esophageal mucosal dissection. A 59-year-old female was admitted to vascular surgery for bilateral lower extremity critical limb ischemia. Patient underwent bilateral above knee amputation and femoro-femoral bypass. Postoperative course was complicated by sepsis and respiratory failure needing mechanical ventilation and acute renal failure requiring hemodialysis in ICU. Patient was also fully anticoagulated with heparin infusion. On day 10 of ICU admission, a nasogastric tube was placed for enteral nutrition. Immediately after nasogastric intubation, patient was noted to have hematemesis and subsequently 2g/dl drop in hemoglobin from baseline. Patient was managed with nil per os, intravenous PPI, fluids and blood transfusions. Heparin infusion was stopped. Emergent EGD was performed, which revealed clots at upper esophagus sphincter (UES) and a linear submucosal track extending from UES to the gastroesophageal junction (GEJ), blood clots and esophagitis in the lower esophagus and normal stomach and duodenum. Patient did not have any bleeding or drop in hemoglobin for next 72 hours. EGD was repeated after 4 days, which showed healing of previously noted esophageal submucosal tract without active bleeding. Over the next week, patient’s condition continued to deteriorate due to ongoing sepsis despite broad spectrum antibiotics and supportive care. Patient’s code status was changed to comfort care as per patient’s wishes. In conclusion, nasogastric intubation can lead to serious complications such as esophageal mucosal dissection. Conservative management is recommended for this rare complication and spontaneous healing is expected outcome. This case highlights the importance of practicing caution while placing nasogastric tube especially in critically ill patients.Figure 1: Esophageal mucosal dissection due to nasogastric intubation.