Gastric Decompression Research Articles

Ultrasound to confirm gastric tube placement in prehospital management

BackgroundIn emergency medicine, the gastric tube (GT) has many purposes, however in prehospital settings, the only indication is gastric decompression. To date, there is lack of recommendation on the diagnostic methods to verify correct GT placement in prehospital. The aim of this study is to estimate diagnostic accuracy of ultrasound in confirming gastric tubes placement in a prehospital setting. MethodThis was a prospective multicentre study conducted in two French towns (Marseille and Grasse) over a one-year period from May 2010 to May 2011. ResultsOne hundred and thirty patients were included in the study with an M/F sex ratio of 77/53 and a mean age of 55.7±19.8 years. The GT position was confirmed by ultrasound, with direct visualization in the gastric area in 116 of the 130 patients. In 14 cases, the ultrasound failed to visualize the tip of the GT; these results were due in 2 cases to gas interposition and in 12 cases the GT was shown by final X-ray to be located in the end of the oesophagus. Direct visualization by ultrasound thus has a sensitivity of 98.3% [94–99.5] and a specificity of 100% [75.7–100], a positive predictive value of 100% and a negative predictive value of 85.7%, Youden's index of 0.98. GT size affects ultrasound visualization; the larger the GT, the easier it is to see. ConclusionBedside ultrasound thus appears to constitute an effective and reliable diagnostic procedure for confirming correct gastric tube placement in prehospital settings.

Superior mesenteric artery compression syndrome - case report

Superior mesenteric artery syndrome is an entity generally caused by the loss of the intervening mesenteric fat pad, resulting in compression of the third portion of the duodenum by the superior mesenteric artery. This article reports the case of a patient with irremovable metastatic adenocarcinoma in the sigmoid colon, that evolved with intense vomiting. Intestinal transit was carried out, which showed important gastric dilation extended until the third portion of the duodenum, compatible with superior mesenteric artery syndrome. Considering the patient's nutritional condition, the medical team opted for the conservative treatment. Four months after the surgery and conservative measures, the patient did not present vomiting after eating, maintaining previous weight. Superior mesenteric artery syndrome is uncommon and can have unspecific symptoms. Thus, high suspicion is required for the appropriate clinical adjustment. A barium examination is required to make the diagnosis. The treatment can initially require gastric decompression and hydration, besides reversal of weight loss through adequate nutrition. Surgery should be adopted only in case of clinical treatment failure.

A Common Fungus, an Unusual (and Deadly) Infection

h i r r n h PRESENTATION We describe a case in which an immunocompetent patient with several comorbid conditions ultimately died of an uncommon infection. A 64-year-old woman with a history of poorly controlled diabetes mellitus type II and chronic alcohol abuse was transferred to our facility for a hepatology evaluation for severe hepatic encephalopathy and fulminant liver failure. Shortly after arrival, she was intubated for airway protection, and a nasogastric tube was placed for gastric decompression. Laboratory studies and a liver biopsy performed shortly after her arrival confirmed a diagnosis of hemochromatosis, with iron deposition noted on the specimen (Figure 1). Within 24 hours of the placement of the nasogastric tube, the patient developed a small area of necrosis at the right nare. Despite immediate removal of the tube, the necrotic area rapidly worsened (Figure 2).

Effective Palliation of Nausea and Vomiting by Retrograde Enterogastric Decompression

Purpose: Intractable nausea and vomiting are recognized complications of gastric cancer which is often unsuitable for decompression by gastrostomy when involvement is diffuse. Venting procedures also inherently require an invasive approach with additional access that entails risks and discomfort. We describe two cases wherein effective palliation was provided by retrograde enterogastric decompression via an existing jejunostomy with a second catheter introduced antegrade for feeding purposes. We are unaware that this approach has previously been described. Methods: Retrospective description of two cases. Results: CASE 1: A 68 year old male with locally advanced diffuse gastric cancer was seen in consultation for intractable nausea and vomiting that required intermittent NG suction. One month previous, he underwent surgery in his home country with CT scan negative for metastatic disease. Cancer was deemed unresectable and a feeding jejunostomy was performed. Subsequent endoscopy revealed diffuse neoplastic involvement of the stomach with no window for venting gastrostomy. Intractable nausea & vomiting were effectively palliated by retrograde enterogastric decompression via the existing jejunostomy. Decompression was maintained for the remaining 11 months of his life during which time he received enteral feedings via the same jejunostomy and intravenous chemotherapy with good performance status until his last month of life. CASE 2: A 60 year old female was diagnosed with poorly differentiated gastric cancer diffusely involving the antrum and distal body of the stomach. Staging laparoscopy prior to anticipated neoadjuvant therapy revealed peritoneal metastasis. Jejunostomy was performed. She was treated on protocol with systemic chemotherapy and maintained on enteral feedings. One month later, she developed intractable nausea and vomiting. Endoscopy revealed diffuse circumferential involvement of the stomach with the extent of malignancy unsuitable for stenting or endoscopic venting gastrostomy. Enterogastric decompression was accomplished with a 12 F pigtail catheter advanced retrograde with an 8 F catheter for feeding introduced antegrade. Effective palliation was accomplished until percutenous gastrostomy by interventional radiology was performed one month later for additional terminal palliation. Conclusion: These cases illustrate the potential for effective palliation of nausea and vomiting in patients with gastric cancer by retrograde enterogastric decompression via an existing jejunostomy. This previously undescribed technique provides a palliative option without supplemental risk to the patient and should be considered when gastric decompression cannot otherwise be accomplished and a jejunostomy is accessible.

AN EXPERIENCE OF SIGMOID COLON VOLVULUS AT EMMERGENCY WARD LRH

BACKGROUND: Sigmoid volvulus is a serious condition due to rotation of sigmoid colon. Volvulusoften presents with abdominal colic and distention. It can be managed conservatively by colonoscopicdecompression, followed by optimization of patient and finally surgical procedure. The present studywas based on the comparison of resection of sigmoid colon and double barrel colostomy or resection andprimary anastomosisOBJECTIVE: Objective of the study was to compare the results of primary anastomosis and colostomyin patients presenting with sigmoid volvulus.METHODOLOGY: In this study a total of 48 patients with sigmoid volvulus coming to Accident &Emergency Department were included. All the patients were examined and investigated. After diagnosisbased on x-ray erect abdomen all the patients were admitted in Accident and Emergency ward. Afteradmission Full Blood count, urea, sugar, S. Electrolysis and ECG were also performed. Patients werecatheterized and a nasogastric tube passed for gastric decompression. All the patients were givenintravenous fluids antibiotics and prepared for surgery as facilities for colonoscopic sigmoidscopicdecompression were not available and decompressions by rectal tube was unsuccessfulRESULTS: Among the cases with sigmoid volvulus there were 36 males and 12 were females. Majority28 cases were in age range of 61-70 years. Eight patients had gangrene of sigmoid colon, 23 patients hadresection and colostomy while 20 had resection and primary anastomosis. Among the postoperativecomplications, 05 patients had wound infection and 01 wound dehiscence. Two patients died because ofsepsis and cardiopulmonary complications.CONCLUSION: Patients presenting as acute abdomen should have urgent laparotomy as soon aspossible. Decompression by colonoscope is the gold standard procedure for stable patients with sigmoidvolvulus. Sigmoidectomy and primary anastomosis is the procedure of choice as it not only avoidssecond admission and operation, but it also avoids the side effects and care of stoma, which is majorcause of morbidity and mortality.

Pneumothorax after nasogastric tube insertion

Nasogastric tubes are often inserted in intensive care settings, the emergency department and hospital wards. Common indications for nasogastric tubes are gastric decompression to palliate bowel obstruction, preventing aspiration in intubated patients and for the delivery of enteral nutrition or medication. A case of pneumothorax following nasogastric tube insertion in a 63-year-old neurosurgical patient is presented with an overview of the literature related to nasogastric tube complications.

The Evolving Role of Post–Ligament of Trietz Nasojejunal Feeding in Enteral Nutrition and the Need for Improved Feeding Tube Design and Placement Methods

Nutrition support is an important link in the chain of therapy for intensive care unit patients. The early institution of nutrition support significantly reduces the incidence of septic complications, reduces mortality, and shortens hospital stay. Unfortunately, impaired gastrointestinal function, particularly gastric atony, restricts the use of nasogastric enteral tube feeding, and the use of this route of administration in these patients can lead to regurgitation, aspiration, and the development of pneumonia. Postpyloric enteral feeding was heralded as a means of overcoming many of these problems. Overall, the results of controlled studies do not support a role of postpyloric duodenal feeding in reducing the incidence of aspiration pneumonia. As a consequence, post-ligament of Treitz nasojejunal enteral feeding is proposed as the technique of choice in these patients. Feeding tube design must incorporate a gastric aspiration port to overcome problems of gastroesophageal acid reflux, duodenogastric bile reflux, and increased gastric acid secretion, problems that occur during "downstream" jejunal feeding. Tube placement technique will need to be refined and patients will need to receive a predigested enteral diet. In postoperative surgical patients in the intensive care unit, there is also a need for a newly designed dual-purpose nasogastric tube capable initially of providing a means of undertaking gastric aspiration and decompression and subsequently a means of initiating nasogastric enteral feeding.

Superior Mesenteric Artery Syndrome Leading to Acute Gastric Dilatation in a Woman with Bulimia

Superior mesenteric artery (SMA) syndrome is a rare clinical disease defined as compression of the third part of the duodenum between the aorta and the SMA. Severe complications of SMA syndrome include acute gastric dilatation which is uncommon but potentially fatal and requires immediate intervention. This report describes a 29‐year‐old woman with SMA syndrome complicated by acute gastric dilatation. It was diagnosed by computerized tomography. The patient had a history of treatment of bulimia nervosa but defaulted 3 months ago. She presented with severe abdominal distension and extreme abdominal pain due to massive gastric dilatation after an eating binge. Gastric decompression was successful with a modified gastric lavage tube with additional large holes at the tip.

Implementation of the evidence review on best practice for confirming the correct placement of nasogastric tube in patients in an acute care hospital

Nasogastric (NG) tube is a device passed through the gastrointestinal tract of patients for the purpose of feeding, gastric decompression and medication administration. However, a small risk involved in the process is that the tube may be misplaced into the trachea during insertion or may get displaced at a later stage, leading to disastrous results. Recent adverse incidences arising out of the misplacement of NG tube raised concerns among the nursing and medical community and the Patient Safety Officer of the hospital. The Evidence Based Nursing Unit, in collaboration with some of the key nursing leaders in nursing administration, was tasked to explore and institute the current best practice in confirming the correct placement of NG tube. The aim of this project was to institute the best practice to confirm the correct placement of NG tube in patients in an acute care hospital setting. The project comprised of a few stages. The first stage involved reviewing the existing recommendations and guidelines on the methods for checking correct NG tube placement. The second stage involved incorporation of the change of practice into the clinical setting. The final stage was to monitor and evaluate the impact of the new practice on the patients, nurses and other healthcare professionals. Evidence search from guidelines and journals supported the test that used pH indicator instead of the litmus test. There is no evidence that supports the method of auscultation and bubbling to confirm correct NG tube placement in the absence of aspirate. Radiology remains the 'gold standard' for checking correct NG tube placement. The revised method of NG tube placement and workflow was incorporated in the revised Standard Operating Procedures. A total of 17 roadshows were conducted to create awareness regarding the new method amongst the nurses, and the implementation of the revised method and workflow was commenced on 3 November 2008. The initial audit conducted 1 month after the practice change was implemented reported 26 (50%) observations of NG tube feeding in 26 audit wards. The key areas of practice change in feeding when tube placement was confirmed (84.6%) and proper testing of aspirate (76.9%) showed good compliance. The implementation of the change in the practice of confirming the correct placement of the NG tube in patients requires good coordination and a multidisciplinary team approach.

Superior mesenteric artery syndrome and acute pancreatitis in a boy with eating disorder: a case report

Eating disorders are an important cause of physical and psychosocial disturbances. Gastrointestinal complications in eating disorders are common and include pancreatitis and superior mesenteric artery syndrome (SMAS). However, only two patients who simultaneously suffered from both SMAS and pancreatitis in the setting of an eating disorder have ever been reported in the literature. We describe here a patient with eating disorder not otherwise specified (ED-NOS) who exhibited both SMAS and pancreatitis concomitantly. An 11-year-old boy with ED-NOS had presented with the sudden onset of recurrent bilious vomiting, abdominal distension and abdominal pain. Laboratory and imaging studies revealed that the patient had SMAS and acute pancreatitis. Gastric decompression and intravenous infusion of fluids promptly improved his abdominal symptoms and laboratory data. This is the first case report of a patient with ED-NOS who simultaneously suffered from SMAS and pancreatitis in the pediatric literature. Since SMAS and pancreatitis can both cause patients to be severely ill, these diseases should be considered in patients with eating disorders who exhibit abdominal symptoms such as vomiting or abdominal pain.

Neglected, Traumatic Duodenal Rupture - Case Report

A case of neglected, double-site, post-traumatic duodenal rupture, which was overlooked at the emergency laparotomy due to intra-abdominal bleeding is presented. For nine days the excessive laceration remained asymptomatic, probably because of visceral adhesions. Both tears of the duodenum were eventually repaired, but symptoms and signs of high mechanical obstruction had developed afterwards, requiring repeated surgery (gastric decompression). Endoscopy performed 2 weeks after duodenal repair showed both, repair site and gastro-jejunal anastomosis permeable. All symptoms quickly with-drawn and the patient recovered. Possible causes of the atypical clinical course in this case were discussed.

Far from Reliable: pH Testing in the Neonatal Intensive Care Unit

Enteral tube placement is a common nursing procedure potentially associated with negative consequences i f malpositioned. A quality improvement model was used to determine if pH testing should be incorporated into the assessment of nasogastric/orogastric tube posit ioning Nasogastric and orogastric tube placement and correct placement verification are common nursing procedures performed in neonatal intensive care units (NICUs) around the world. Enteral tubes can be of great benefit to patients, allowing for nutritional support, medication delivery, assessment, and gastric decompression in premature and term infants. Although the procedure may be common, severe complications can arise if malpositioned in sites other than gastrointestinal. Although costly and impractical, chest radiographs remain the gold standard, allowing for direct tube visualization and placement verification. Nonradiographic bedside testing methods, although less reliable than radiography, are commonly used. Multiple bedside testing techniques exist, such as aspiration, auscultation, tube marking comparisons, and pH testing. Bedside placement verification tests are cost-effective and provide immediate results. Currently, there is a lack of research identifying the best method of verifying enteral tube location in neonates. The purpose of this literature review and pH pilot study was to determine what the best method is for verifying tube placement, if adequate aspirates could be obtained, and if pH readings are a reliable method of tube placement verification in neonates using the quality improvement model Plan-DoStudy-Act (PDSA) cycle. within the Neonatal Intensive Care Unit at Texas Children's Hospital. PDSA Cycle

The Utility of Nasogastric Decompression After Intestinal Surgery in Children

Evaluation of: Davila-Perez R, Bracho-Blanchet E, Tovilla-Mercado JM et al.: Unnecessary gastric decompression in distal elective bowel anastomoses in children: a randomized study. World J. Surg. 34(5), 947–953 (2010). Although the use of nasogastric decompression after intestinal surgery has been a common practice for decades, there has not been a prospective randomized trial that supports its purported benefits in children. Davila-Perez and colleagues undertook a scientific approach to the use of nasogastric decompression in children undergoing intestinal anastomoses to determine if clinical benefits could be identified. They randomized 60 pediatric patients undergoing intestinal anastomoses to either undergo nasogastric decompression for 5 days or to not have gastric decompression during the postoperative period. The study was designed as an equivalence study, with a goal to demonstrate that there was equivalence between the treatment arms. The results, with the use of sophisticated statistics, supported the authors conclusions that there is no difference in the postoperative course of pediatric patients that undergo gastric decompression when compared with those not undergoing gastric decompression, and that routine use of gastric decompression should be eliminated.

Relief of Superior Mesenteric Artery Syndrome with Correction of Multiplanar Spinal Deformity by Posterior Spinal Fusion

Superior mesenteric artery syndrome is obstruction of the third portion of the duodenum by compression between the abdominal aorta and superior mesenteric artery. Pediatric orthopedists are familiar with this entity, as the association between superior mesenteric artery syndrome and spinal fusion or body casting has been well established. However, patients with spinal deformities usually experience superior mesenteric artery syndrome after orthopedic intervention, with rates after corrective spinal surgery reported between 0.5% and 2.4%. Symptoms of superior mesenteric artery syndrome typically include nausea, bilious emesis, abdominal pain, early satiety, and anorexia. Initial treatment focuses on gastric decompression and maintaining euvolemia and electrolyte balance. The patient should receive enteral nutrition via nasojejunal tube or parenteral nutrition to allow for weight gain and subsequent resolution of the obstruction. The superior mesenteric artery takes off from the duodenum at an angle of 45 degrees to 60 degrees in normal individuals. The third portion of the duodenum is suspended between these vessels by the ligament of Treitz. Any variation in this relationship that decreases the arteriomesenteric angle may induce obstruction. Specifically, lumbar hyperextension or hyperlordosis can traction the mesentery and vessels. Only 2 cases of superior mesenteric artery syndrome in patients with sagittal plane spinal deformity have been described in the literature. In patients with concomitant superior mesenteric artery syndrome and spinal deformity, correction of the deformity may help alleviate the obstruction and result in faster recovery. The contribution of spinal column deformity to the arteriomesenteric angle should not be overlooked.

Association between outcome and changes in plasma lactate concentration during presurgical treatment in dogs with gastric dilatation-volvulus: 64 cases (2002–2008)

To determine whether changes in presurgical plasma lactate concentration (before and after initial fluid resuscitation and gastric decompression) were associated with short-term outcome for dogs with gastric dilatation-volvulus (GDV). Retrospective case series. 64 dogs. Medical records were reviewed, and signalment, history, resuscitative treatments, serial presurgical lactate concentrations, surgical findings, and short-term outcome were obtained for dogs with confirmed GDV. 36 of 40 (90%) dogs with an initial lactate concentration <or= 9.0 mmol/L survived, compared with only 13 of 24 (54%) dogs with a high initial lactate (HIL) concentration (> 9.0 mmol/L). Within HIL dogs, there was no difference in mean +/- SD initial lactate concentration between survivors and nonsurvivors (10.6 +/- 2.3 mmol/L vs 11.2 +/- 2.3 mmol/L, respectively); however, there were significant differences in post-treatment lactate concentration, absolute change in lactate concentration, and percentage change in lactate concentration following resuscitative treatment. By use of optimal cutoff values within HIL dogs, survival rates for dogs with final lactate concentration > 6.4 mmol/L (23%), absolute change in lactate concentration <or= 4 mmol/L (10%), or percentage change in lactate concentration <or= 42.5% (15%) were significantly lower than survival rates for dogs with a final lactate concentration <or= 6.4 mmol/L (91%), absolute change in lactate concentration > 4 mmol/L (86%), or percentage change in lactate concentration > 42.5% (100%). Calculating changes in plasma lactate concentration following initial treatment in dogs with GDV may assist in determining prognosis and identifying patients that require more aggressive treatment.

Pharyngostomy tubes for gastric conduit decompression

This article illustrates our operative technique for pharyngostomy tube placement and describes our clinical experience with pharyngostomy use for gastric conduit decompression after esophagectomy. We retrospectively reviewed patients undergoing pharyngostomy tube placement for gastric conduit decompression after esophagectomy from January 2008 to August 2009. Patients were included if they had a pharyngostomy tube placed at esophagectomy (prophylactic placement) or as a means of decompression after postesophagectomy anastomotic leak (therapeutic placement). We collected operative and clinical data and performed a descriptive statistical analysis. We placed 25 pharyngostomy tubes for gastric conduit decompression after esophagectomy. Eleven were placed prophylactically (44%); the remaining 14 were placed therapeutically (56%) after anastomotic leak. Prophylactic pharyngostomy tubes remained in place a median of 8 days (range 4-17 days), whereas therapeutic pharyngostomy tubes were left in place a median of 15 days (range 7-125 days). There were 4 infectious complications (16%) unrelated to length of pharyngostomy use: 2 cases of cellulitis (resolved with antibiotics, tube remaining in place) and 2 superficial abscesses after tube removal requiring bedside débridement. Seventy-two percent of patients underwent swallow evaluation; 22% of these patients had radiographic evidence of aspiration. Pharyngostomy tube placement for gastric conduit decompression after esophagectomy is simple, and tubes can stay in place for prolonged periods. Our experience suggests that pharyngostomy tubes are a safe alternative to nasogastric drainage.

The effect of gastric decompression on postoperative nausea and emesis in pediatric, tonsillectomy patients

The effect of gastric decompression on postoperative nausea and emesis in pediatric, tonsillectomy patients

Dolor abdominal en paciente con bulimia nerviosa

The incidence of bulimia nervosa has attained significance in the last decades in the Western countries. Massive gastric dilatation is a very serious condition that is extremely rare in patients with no background of gastrointestinal disease. However, several cases have been reported in patients with eating disorders, particularly after a compulsive ingestion. Complications of acute gastric dilatation are infarction and perforation with severe and irreversible shock. Prompt diagnosis of acute gastric dilatation and decompression of the stomach even when gastric ischemia and mucosal necrosis is present may avoid unnecessary laparotomy. Careful investigation of eating habits may result in therapeutic gastric emptying at an earlier stage. We present a case of a 24-year old woman who suffered bulimia nervosa and was admitted because of acute gastric dilatation. We review the most important features of this condition.

Unnecessary Gastric Decompression in Distal Elective Bowel Anastomoses in Children: A Randomized Study

The goal of this study was to investigate the role of nasogastric drainage in preventing postoperative complications in children with distal elective bowel anastomosis. Nasogastric drainage has been used as a routine measure after gastrointestinal surgery in children and adults to hasten bowel function, prevent postoperative complications, and shorten hospital stay. However, there has been no study that shows in a scientific manner the benefit of nasogastric drainage in children. We performed a clinical, controlled, randomized trial comprising 60 children who underwent distal elective bowel anastomoses and compared postoperative complications between a group with nasogastric tube in place (n = 29) and one without it (n = 31). Demographic data and diagnoses were comparable in both groups (P = NS). No anastomotic leaks or enterocutaneous fistulae were found in any patient. There were no significant differences between the two groups with respect to abdominal distension, infection, or hospital stay. Only one patient in the experimental group required placement of the nasogastric tube due to persistent abdominal distension (3.2%). The routine use of nasogastric drainage after distal elective intestinal surgery in children can be eliminated. Its use should depend on the individual patient's situation.

Effect of Physician Education and Patient Counseling on Inpatient Nonsurgical Percutaneous Feeding Tube Placement Rate, Indications, and Outcome

The decision to place a percutaneous feeding tube (PFT) in patients who are at the end of life is multidimensional and often complicated. We assessed the effect of physician education and counseling for patients and their surrogates on inpatient nonsurgical (endoscopic and radiologic) PFT placement rates, indications, complications, and mortality. In a pre-paid group practice, a geriatrician initiated a program of physician education and patient/surrogate counseling on the ethical and nutritional aspects of long-term enteral feeding. We compared rates of nonsurgical PFT placement (excluding those for cancer therapy or gastric decompression), indications, complications, and short- and long-term mortality in adult inpatients before (2004) and after (2005) the program. In 2004 and 2005, 115 and 60 inpatients underwent PFT placement, respectively. The annual number of hospital admissions was similar, but the rate of PFT placement declined (0.80% vs. 0.44%, P < 0.0001). The indications were cerebrovascular accident (42 [37%] versus 22 [37%]), dementia (15 [13%] versus 3 [5%]), other neurological disease (28 [24%] versus 16 [26%]), and miscellaneous disease (30 [26%] versus 19 [32%]); P > 0.05. Severe infectious complications occurred in 4 (3%) versus 0 (0%) patients, P > 0.05. Mortality (2004 versus 2005) at 30 days (23 [20%] versus 11 [18%]), 1 year (62 [54%] versus 29 [48%]) and 2 years (72 [63%] versus 31 [52%]) was similar, P > 0.05. A pilot program of educating referring physicians and counseling patients and their surrogates reduced the rate of inpatient PFT placement by nearly 50%. Indications, severe complications and short- and long-term mortality remained unchanged.