Fatal consequences of nasogastric intubation: a clinical reminder

Abstract

A 69-year{old woman presented to A&E with atwo{day history of malaise, lower back pain andvomiting. Her abdomen was soft and non{distended, with mild tenderness in the epigas-triumandnormalbowelsounds.Herpastmedicalhistory included previous open cholecystectomyfor acute cholecystitis, and a subsequentlaparotomy for severe adhesional bowel obstruc-tion with creation of a permanent ileostomy. Fol-lowing this procedure she developed a massiveincisional hernia. She was not known to haveoesophagitis or peptic ulcer disease, and was notreceiving any form of gastric acid suppression.She was initially managed conservatively withomeprazole while awaiting upper gastrointestinalendoscopy. Two days into the admission thepatientbecamemoreunwell,withderangementofher renal function. There was clinical evidence ofperitonitis and CT scan revealed extensive intra-peritoneal free fluid and air consistent with intes-tinal perforation. A laparotomy was performed atwhich a large perforated anterior duodenal ulcerwasdiscoveredandoversewn.Theprocedurewascomplicated by both the incisional hernia andextensive adhesions. During adhesionolysis, anenterotomy occurred necessitating limited resec-tion and end{to{end anastomosis. Her initialpostoperative recovery was satisfactory but14 days after the surgery she deteriorated sud-denly. A further laparotomy was performed atwhichgrossfaecalcontaminationoftheperitonealcavity was evident and a small bowel perforationidentified, which was resected.Her subsequent recovery followed a verystormy course. The patient became very de-pressed,andconsequentlyheroralintakedroppedand she required nutritional support. It was feltthat feeding via the enteral route would be prefer-able, and that the risks of bloodstream infectionandseveresepsisinamalnourishedpatientwithaheavily contaminated open wound outweighedthe benefits of parenteral nutrition. Nasogastricfeeding was therefore instituted using a fine{borefeeding tube. Once this was established her physi-cal condition slowly improved, as evidenced byslow but progressive wound healing. She re-mainedonprotonpumpinhibitorsthroughoutherhospitaladmission.Herdepression,however,tooklonger to resolve and nasogastric feeding wascontinued for approximately three months.When oral nutrition was finally recommenced,the patient complained of dysphagia and was ableto tolerate only small and infrequent boluses ofsolidfood.Threedayslater,melaenawasobservedfrom the ileostomy, and her haemoglobin fell from12.1 g/dL to 8.2 g/dL, associated with haemody-namicinstability.Anemergencyoesophagoduode-noscopy was performed. This revealed thenasogastric tube in situ (Figure 1a) with an associ-ated 6 cm inflammatory oesophageal stricture(Figure 1b), which was balloon dilated. In theanterior mid{corpus of the stomach, there wasfocal gastritis with ulceration (Figure 1c), whichwas injected with adrenaline. Both abnormalities