Feasibility of Nasogastric Tube Feeding Into Type III Hiatal Hernia

Abstract

Critical illness predisposes patients to malnutrition, leading to complications such as muscle wasting, weakness, increased risk of infection, and death. Compared to parenteral nutrition, enteral nutrition has a lower risk of complications1. Here we describe placement of a nasogastric (NG) tube into a type III hiatal hernia with resultant coiling of the tube above the diaphragm. The patient was an 83 year old woman with history of a large hiatal hernia seen on endoscopy in 2011, heart failure, diabetes, obstructive sleep apnea, and COPD who initially presented to the hospital with an exacerbation of heart failure and COPD initially requiring bi-level positive airway pressure ventilation (BIPAP), course complicated by multidrug-resistant pseudomonas pneumonia from aspiration requiring intubation. While intubated, the patient had an orogastric tube successfully placed in the hiatal hernia and was eventually weaned to BIPAP with concomitant removal of the orogastric tube. Due to persistently altered mentation NGT placement was attempted but resulted in coiling above the diaphragm. As the patient had received no feeding for several days, gastroenterology was consulted for placement of a percutaneous endoscopic gastrostomy tube. Due to the patient's tenuous respiratory status, and her goals of care to avoid intubation, this was deferred. An NG tube was again placed with aspiration revealing feculent material. Portable one-view chest X-ray demonstrated coiling of the tube above the diaphragm, but subsequent CT scan of the abdomen revealed the NG tube was indeed coiled inside the hiatal hernia as the majority of the stomach had herniated above the diaphragm. Feeds were initiated at 10 ml/hr increasing to 40ml/hr, which the patient tolerated without high residuals. In this scenario, proper positioning of the NG tube in the stomach resulted in a supradiaphragmatic position. Only 5% of hiatal hernias are type III and IV2. A literature review shows few cases with roentgenography of NG tube placement in presumed hiatal hernias,3,4 and clinical outcomes were unknown. In this case, we demonstrated the feasibility of NG tube feeding into a supradiaphragmatic stomach in select high risk individuals without alternative means of nutrition. Risks, such as reflux, aspiration, procedural sedation and goals of care must be considered prior to initiating feeds into a supradiaphragmatic stomach.3091_A Figure 1. NGT in stomach3091_B Figure 2. supradiaphragmatic stomach3091_C Figure 3. KUB of NGT placement