Unusual Complication of Salem Sump Tube

Abstract

Purpose: Enteral nutrition is a major component of therapy in critically ill patients. Feeding tubes passed through the nose or mouths are commonly used to administer medications and enteral nutrition, as well as to manage post-operative ileus. We report a case of an unusual complication associated with an orogastric tube (OGT). Methods: A 45 year old man with Hepatitis C, HIV, rectal squamous cell carcinoma status post radiotherapy was electively admitted for abdomino-perineal resection because of recurrent cancer. Post operatively, he was being maintained on mechanical ventilation. He was receiving intravenous midazolam for sedation, intramuscular ketorolac for pain management and enteral nutrition via OGT for nutritional support. On day 6, the patient had a self-limited episode of hematamesis. The ketorolac was discontinued and he was put on intravenous esomeprazole. Endoscopic investigation was deferred as the patient was febrile, hemodynamically stable and had OGT aspirate revealing clear bilious fluid. The next day, he was found to have chewed through the OGT; the external piece of the tube was found outside his mouth. Radiographs confirmed the presence of the rest of the tube in the esophagus and stomach. EGD was performed. The tip of the remnant OGT was seen at 24 cm in the esophagus. It was pushed into the stomach, snared and removed through an overtube. A large ulcer was noted beginning 2 cm above the gastroesophageal junction (GEJ) and extending into the cardia of the stomach. A visible vessel was noted in the ulcer which was injected with epinephrine and cauterized using a gold probe. Results: The patient had no further bleeding episodes but succumbed to his other comorbidities the following week. Conclusion: In our case, even though the patient was intubated and sedated, he managed to chew through the OGT and swallow the tube remnant. This case highlights the point that care must be taken to prevent damage to the OGT by placing a bite block or oral airway, despite the fact that the patient might be mechanically ventilated and sedated. Another important point to note is that even though the OGT had been in place for a short duration prior to endoscopic evaluation, this patient had developed a large ulcer at the GEJ along the course of the tube. While NSAID administration may have played a significant role in causing the ulcer, the case nonetheless emphasizes the importance of prescribing proton pump inhibitors to critically ill patients to protect against GI bleeding, particularly in patients with additional risk factors for mucosal injury.