Enteric Tube Placement in Patients With Known Esophageal Varices: Risks and Predictors of Post-Insertion Gastrointestinal Bleeding

Abstract

Introduction: Placement of enteric tubes in cirrhotic patients with portal hypertension is often approached with caution due to the risk of rupture and hemorrhage of esophageal varices (EV). However, the incidence and predictors of gastrointestinal bleeding (GIB) with enteric tube placement in patients with known esophageal varices has not been well described. Methods: We conducted a retrospective review of patients with known EV admitted from January 2010 to January 2017. Patients with endoscopy proven EV and nasogastric or orogastric tube placement confirmed by imaging were included. Patients admitted with GIB were excluded. Demographic data, etiology of liver disease, grade and location of EV, use of beta blocker, previous EV bleed or banding, history of encephalopathy, presence of ascites, baseline labs and MELD score were collected. The primary endpoint was incidence of hematemesis, melena, or hematochezia after enteric tube insertion or during hospitalization. The secondary endpoint was hemoglobin (Hb) drop by more than 2 g/dl within 24 hours of enteric tube placement; patients who underwent liver transplantation during hospitalization were excluded from this analysis. Results: Out of 63 patients, 64% were male and mean age was 58. Hepatitis C was the most common cause of cirrhosis (37%) followed by alcohol related cirrhosis (25%). Forty-four percent of patients had grade 1 EV and 71% of patients had EV located in the lower third of the esophagus. Thirty percent had previous EV bleed while 24% had previous EV banding. The most common indication for admission was altered mental status. Baseline laboratory values prior to enteric tube placement were Hb 9.05 g/dl, INR 2.01, platelets 82.3 109/L. Average MELD score prior to enteric tube placement was 24.3. Over 80% of patients had nasogastric tubes with 40% of all tubes inserted by physicians. The primary outcome of hematemesis occurred in 8 patients (13%) while melena/hematochezia occurred in 9 patients (14%). The secondary outcome of Hb drop, evaluated in 46 patients, was observed in 6 patients (13%). On univariate analysis using logistic regression model, MELD score was the only significant predictor of GIB (P=0.04). Conclusion: Post-enteric tube placement GIB occurred in 27% of patients with known EV. MELD score was the only predictor of GIB. Larger studies are needed to further evaluate the risk and predictors of bleeding after enteric tube placement in patients with esophageal varices.Table: Table. Patient DemographicsTable: Table. Characteristics of Enteric Tube Placement