A case report of esophageal perforation: Complication of nasogastric tube placement

Esophageal perforation and epidural emphysema as complications of nasogastric tube placement

We present a 72-year-old man with end-stage renal disease and Hashimoto encephalopathy in whom a diagnosis of epidural emphysema because of esophageal perforation by a nasogastric tube placement. Although its imaging findings may be alarming to clinicians, close monitoring and conservative treatment are advisable.

The clinical effectiveness of the corrected nose-earlobe-xiphoid distance formula in determining the internal length of a nasogastric tube in adults: A retrospective study

INTRODUCTION

Accurate determination of the internal length of nasogastric tubes is essential for the safe and effective completion of blind insertions, a routine nursing procedure. The widely used nose-earlobe-xiphoid distance lacks evidence and effectiveness. A recent randomized controlled trial proposed an alternative, the corrected nose-earlobe-xiphoid distance formula. However, its effectiveness in real-world clinical practice has not yet been studied.

OBJECTIVE

This study assessed the real-world clinical effectiveness of the corrected nose-earlobe-xiphoid distance formula for determining the internal nasogastric tube length in adult patients admitted to hospitalization or intensive care units.

DESIGN

A single-center retrospective clinical effectiveness study was conducted, utilizing routinely collected observational data.

SETTING AND MAIN OUTCOME MEASURES

Between October 2020 and November 2022, 358 adult patients in a general hospital requiring a nasogastric feeding tube were included. The primary outcome involved assessing nasogastric tube tip positioning (>3 cm below the lower esophageal sphincter) by an advanced practice nurse through X-ray verification. Secondary outcomes, obtained from patient records for a random subgroup of 100 participants, were reporting clarity and evaluation of the tip position by reviewing radiologists.

RESULTS

Following evaluation by an advanced practice nurse, all nasogastric feeding tubes were determined to be correctly positioned. Among the subgroup of 100 tubes, X-ray protocols, as documented by the reviewing radiologists, showed varying levels of reporting clarity for the tube tip: 4.0 % lacked reporting, 33.0 % had ambiguous reporting and 63.0 % had unambiguous reporting.

CONCLUSION

The corrected nose-earlobe-xiphoid distance formula demonstrates potential to emerge as a safer alternative to existing methods for determining the internal length of nasogastric tubes.

IMPLICATIONS FOR CLINICAL PRACTICE

In addition to healthcare provider education and training, a checklist-based framework is recommended for radiologists to unambiguously report nasogastric tube tip positions.

Complex Refractory Esophageal Stricture Due to Chronic Gasoline Ingestion: A Case Report

Esophageal stricture is a narrowing of the esophageal lumen which is often characterized by impaired swallowing or dysphagia. It can be induced by inflammation, fibrosis or neoplasia which damages the mucosa and/or submucosa of the esophagus. Corrosive substance ingestion is one of the major causes of esophageal stricture, particularly in children and young adults. For instance, accidental ingestion or attempted suicide with corrosive household products is not uncommon. Gasoline is a liquid mixture of aliphatic hydrocarbons derived from the fractional distillation of petroleum, which is then combined with additives such as isooctane and aromatic hydrocarbons (e.g., toluene and benzene). Gasoline also contains several other additives including ethanol, methanol and formaldehyde, which make it a corrosive agent. Interestingly, to the best of our knowledge, the incidence of esophageal stricture caused by chronic gasoline ingestion has not been reported. In this paper, we report the case of a patient with dysphagia due to complex esophageal stricture due to chronic gasoline ingestion who underwent a series of esophago-gastro-duodenoscopy (EGD) procedures and repeated esophageal dilation.

The Forgotten Complication of Nasogastric Tube Insertion: Esophageal Perforation and Associated Hydropneumothorax and Hydropneumoperitoneum

Nutritional support is essential for critically ill patients to reduce mortality and length of stay. Frequently nasogastric (NG) tubes are used to provide enteral nutrition. A very rare risk of NG tube placement is esophageal perforation, most commonly in the thoracic portion of the esophagus. Here we describe a case of a 41-year-old male with multiple risk factors for esophageal integrity disruption who initially presented for diabetic ketoacidosis (DKA) requiring intubation. Following intubation, an NG tube was placed for nutritional support. The following day the patient developed hydropneumothorax and hydropneumoperitoneum. He was taken emergently for surgical correction of suspected perforation. It was found that the patient had esophageal perforation from the distal esophagus to the proximal portion of the lesser curvature of the stomach. The NG tube transversed the proximal portion of the tear and re-entered at a distal site. The distal portions of the esophagus showed necrotic superficial layers with viable muscularis layers. The patient gradually improved after surgical intervention and was discharged to a long-term acute care facility. It is essential as medical providers to be familiar with complications of NG tube placement and risk factors that could increase the risk of esophageal perforation.

A Case Report of Esophageal Perforation: Complications of Orogastric Tube Placement

Orogastric tube (OGT) insertion is a routine procedure in medical care. It is often inserted in patients after endotracheal intubation. OGT insertion is often a blind procedure. Misplacement of the tube can cause a variety of complications and can sometimes be life-threatening. We present the case of a 71-year-old male patient who experienced a rare proximal esophageal perforation as a complication of blind insertion of the OGT; he required OGT insertion after receiving endotracheal intubation for hypoxic respiratory failure secondary to COVID-19 infection. The esophageal perforation was revealed on a post-procedural roentgenogram and confirmed by a subsequent computed tomography of the chest. Given the small size of the perforation and the absence of clinical instability, conservative management was pursued leading to improvement of the mediastinitis. Although the complications of OGT insertion are uncommon, their consequences can be potentially serious and require a high degree of suspicion.

Comparison of different methods of nasogastric tube insertion in anesthetized and intubated patients: A meta-analysis

BACKGROUND

Several techniques of nasogastric tube (NGT) insertion have been described in the literature with different success rates.

AIM

To systematically search the literature and conduct a meta-analysis comparing the success rates, insertion time and complications associated with different techniques of NGT insertion in anesthetized and intubated patients.

METHODS

An electronic search of the PubMed, Scopus, CENTRAL (Cochrane Central Register of Controlled Trials), and Google Scholar databases were performed up to October 31, 2019. We included 17 randomized controlled trials with 2500 participants in the meta-analysis.

RESULTS

As compared to the conventional method, successful insertion of the NGT on first attempt was higher with modified techniques such as the reverse Sellick’s maneuver [relative risk (RR) 1.94; 95% confidence interval (CI): 1.62-2.31], use of a frozen NGT (RR 1.55; 95%CI: 1.13-2.13), inserting the NGT with neck flexion and lateral neck pressure (RR 1.64; 95%CI: 1.10-2.45), endotracheal tube-assisted (RR 1.88; 95%CI: 1.52-2.32) and video-assisted placements (RR 1.60; 95%CI: 1.31-1.95). All the modified techniques also led to comparatively higher insertion success rates than the conventional technique.

CONCLUSION

The use of modified techniques of NGT insertion such as the reverse Sellick’s maneuver, neck flexion with lateral neck pressure, frozen NGT, endotracheal tube-guided or video-assisted methods result in a significantly better chance of successful tube insertion at first attempt as compared to the conventional technique. All modified techniques also significantly improve the overall chance of successful NGT placement as compared to the conventional method.

Bedside Abdominal Ultrasound in Evaluating Nasogastric Tube Placement: A Multicenter, Prospective, Cohort Study

BACKGROUND

Chest radiography is universally accepted as the method of choice to confirm correct positioning of a nasogastric tube (NGT). Considering also that radiation exposure could increase with multiple insertions in a single patient, bedside abdominal ultrasound (BAU) may be a potentially useful alternative to chest radiography in the management of NGTs.

RESEARCH QUESTION

What is the accuracy of BAU in confirming the correct positioning of an NGT?

STUDY DESIGN AND METHODS

After a specific course consisting of 10 h of training, the authors studied, in a prospective multicenter cohort, the validity of BAU to confirm correct NGT placement. All patients were also evaluated by auscultation (whoosh test) and by chest radiography. Every involved operator was blind to each other. Interobserver agreement and accuracy analyses were calculated.

RESULTS

This study evaluated 606 consecutive inpatients with an indication for NGT insertion. Eighty patients were excluded for protocol violation or incomplete examinations and 526 were analyzed. BAU was positive, negative, and inconclusive in 415 (78.9%), 71 (13.5%), and 40 (7.6%), respectively. The agreement between BAU and chest radiography was excellent. Excluding inconclusive results, BAU had a sensitivity of 99.8% (99.3%-100%), a specificity of 91.0% (88.5%-93.6%), a positive predictive value of 98.3% (97.2%-99.5%), and a negative predictive value of 98.6% (97.6%-99.7%). The accuracy of BAU slightly changed according to the different assignments of the uncertain cases and was improved by the exclusion of patients with an altered level of consciousness.

INTERPRETATION

These results suggest that BAU has a good positive predictive value and may confirm the correct placement of NGTs when compared with chest radiography. However, considering its suboptimal specificity, caution is necessary before implementing this technique in clinical practice.

Haemorrhagic exfoliative oesophagitis associated with nasogastric tube placement

A 92-year-old man hospitalised for cerebral infarction developed haematemesis. The patient was taking low-dose aspirin and apixaban for his cerebral infarction and non-valvular atrial fibrillation. His enteral nutrition was administrated through nasogastric tube. Upper endoscopy revealed active bleeding from a protruded lesion in the upper oesophagus. The lesion was removed by washing with a water jet, followed by successful endoscopic haemostasis. Histopathological examination revealed degenerated squamous epithelium without specific findings; the diagnosis was exfoliative oesophagitis. In our case, mechanical mucosal injury caused by nasogastric tube placement may result in exfoliative oesophagitis. In addition, the use of low-dose aspirin with apixaban may have contributed to the bleeding. We then performed a wire-guided nasogastric tube placement under fluoroscopy. No further bleeding was observed, but the patient died of sepsis 1 month later. This case highlights the importance of a risk assessment and management of oesophageal complications associated with nasogastric tube placement.

Massive subcutaneous emphysema after traumatic pneumothorax

A simple case/asymptomatic pneumothorax not deemed to necessitate drainage can quickly change, and patient safety can be compromised. Chest tube insertion with increased suction is considered a safe and efficient strategy in patients with extensive subcutaneous emphysema following traumatic pneumothorax.

Clinical outcomes and safety of high-resolution manometry guided superficial partial circular muscle myotomy in per-oral endoscopic myotomy for Jackhammer esophagus: Two cases report

BACKGROUND

Jack hammer esophagus is a relatively rare disease and to date, there is no dramatic treatment option. Recently, conventional per-oral endoscopic myotomy (POEM) have expanded their area into Jackhammer esophagus. However, several complications such as post procedure motility disorders (e.g., passage disturbance) are issues after POEM. To overcome these issues, we here introduced high-resolution manometry (HRM)-guided superficial partial circular muscle myotomy, which involves cutting only the superficial layer of the esophageal circular muscle.

CASE SUMMARY

We report two cases of patients with Jackhammer esophagus who were treated with HRM-guided extremely superficial partial circular muscle myotomy during POEM. Case 1 was a 53-year-old female with medication-refractory odynophagia and case 2 was a 47-year-old man who presented with chest pain. They were diagnosed with Jackhammer esophagus using HRM, and the hypercontractile segments of the esophagus were identified. HRM-guided extremely superficial partial circular muscle myotomy was performed while preserving the lower esophageal sphincter. Therefore, the circular and longitudinal muscle layers are preserved but hypercontractile movements are reduced, even after POEM. Patients’ clinical symptoms dramatically improved right after POEM, and 6-mo follow-up HRM revealed completely resolved status. During a 1-year follow-up period, patients were still in good health and remained symptom free.

CONCLUSION

HRM-guided superficial partial circular muscle myotomy may be a promising alternative to conventional POEM for treating Jackhammer esophagus with improved efficacy.

Acute Phlegmonous Esophagogastritis Causing Respiratory Distress

Phlegmonous esophagogastritis is an extremely rare condition characterized by diffuse inflammation of the upper gastrointestinal tract, sparing the mucosa. Patients can present with an acute onset of symptoms, and computed tomography scans can show diffusely edematous wall with intramural low attenuation surrounded by ring enhancement. Here we report such a case of a man who presented with central chest pain and breathing difficulty. The patient developed respiratory distress due to compression of trachea by the edematous esophagus.

Nasogastric Tubes Can Cause Intramural Hematoma of the Esophagus

Patient: Male, 84

Final Diagnosis: Intramural hematoma of esophagus

Symptoms: Chest pain • hematemesis

Medication: —

Clinical Procedure: Esophagogastroduodenoscopy

Specialty: Gastroenterology and Hepatology

Enteral Access Devices: Types, Function, Care, and Challenges

Enteral access feeding devices are placed in patients who have a functional and accessible gastrointestinal (GI) tract but are not able to consume or absorb enough nutrients to sustain adequate nutrition and hydration. For many individuals, enteral nutrition support is a lifesaving modality to prevent or treat a depleted nutrient state that can lead to tissue breakdown, compromised immune function, and poor wound healing. Psychological well-being is also affected with malnutrition and dehydration, triggering feelings of apathy, depression, fatigue, and loss of morale, negatively impacting a patient's ability for self-care. A variety of existing devices can be placed through the nares, mouth, stomach or small intestine to provide liquid nutrition, fluids, and medications directly to the GI tract. If indicated, some of the larger-bore devices may be used for gastric decompression and drainage. These enteral access devices need to be cared for properly to avert patient discomfort, mechanical device-related complications, and interruptions in the delivery of needed nutrients, hydration, and medications. Clinicians who seek knowledge about enteral access devices and actively participate in the selection and care of these devices will be an invaluable resource to any healthcare team. This article will review the types, care, proper positioning, and replacement schedules of the various enteral access devices, along with the prevention and troubleshooting of potential problems.

Bilateral Pneumothoraces in a Trauma Patient After Dobhoff Tube Insertion

Patient: Male, 74

Final Diagnosis: Pneumothorax

Symptoms: Hypoxemia • shortness of breath

Medication: —

Clinical Procedure: —

Specialty: Surgery

Nasogastric tube knotting: a rare and potentially overlooked complication among healthcare professionals

Nasogastric tube placement is a common procedure performed in surgical and medical specialities. The occurrence of knot formation is perhaps one of the least well-recognised complications associated with its usage. We present a case of nasogastric tube knotting to remind colleagues of this rare but important complication. A 75-year-old woman with adhesional bowel obstruction was admitted under the general surgery team. A wide bore nasogastric tube was inserted for drainage and decompression. Although placement of the tube was deemed to be successful, there was no drainage of gastric content evident. On removal of the 'non-functioning' tube a simple knot was seen at its proximal end. A further nasogastric tube was placed and the patient's symptoms resolved with conservative management. Nasogastric tube knotting is a rare and often overlooked complication with the potential to cause significant trauma on tube removal if unrecognised.

Nasogastric Tube Feeding-Induced Esophageal Bezoar: Case Description

Background. Bezoars are well established entities causing gastrointestinal obstructions. Depending on the prominent constituent of these bezoars, the latter are divided into four subtypes: pharmacobezoars, lactobezoars, trichobezoars, and phytobezoars. Less frequently reported types of bezoars are reported including those formed secondary to nasogastric tube feeding with casein-based formulas. Case Presentation. A 69-year-old male presented following cardiac arrest postmyocardial infarction. Patient sustained anoxic brain injury after resuscitation, rendering him ventilator dependant along with nasogastric tube feeding, initially. Dislodging of the nasogastric tube at one time rendered it difficult to reinsert it, with investigation showing the presence of calcified material within the distal oesophagus, mainly composed of casein-based products secondary to enteral feeding. Conclusion. Bezoars are well known to cause gastrointestinal obstructions due to their indigestible characteristics within the alimentary tract. More rare causes of bezoars include those formed from casein-based feeding formulas administered to patients with sustained enteral feeding. Esophageal obstruction, secondary to casein-based bezoars, occurs due to multiple risk factors, especially in those necessitating intensive care. Approach in such scenarios requires a multiteam approach.

A Rare Case of Acute Phlegmonous Esophagogastritis Complicated with Hypopharyngeal Abscess and Esophageal Perforation

Patient: Female, 60

Final Diagnosis: Acute phlegmonous esophagogastritis complicated with hypopharyngeal abscess • esophageal perforation

Symptoms: Fever • painful swallowing • chest pain

Medication: —

Clinical Procedure: Drainage • debridement • esophageal reconstruction

Specialty: Surgery

Intraoperative Gastric Tube Intubation: A Summary of Case Studies and Review of the Literature

Study Objective

Establish complications and risk factors that are associated with blind tube insertion, evaluate the validity of correct placement verification methods, establish the rationales supporting its employment by anesthesia providers, and describe various deployment facilitators described in current literature.

Measurements

An exhaustive literature review of the databases Medline, CINAHL, Cochrane Collaboration, Scopus, and Google Scholar was performed applying the search terms “gastric tube”, “complications”, “decompression”, “blind insertion”, “perioperative”, “intraoperative” in various order sequences. A five-year limit was applied to limit the number and timeliness of articles selected.

Main Results

Patients are exposed to potentially serious morbidity and mortality from blindly inserted gastric tubes. Risk factors associated with malposition include blind insertion, the presence of endotracheal tubes, altered sensorium, and previous tube misplacements. Pulmonary aspiration risk prevention remains the only indication for anesthesia-related intraoperative use. There are no singularly effective tools that predict or verify the proper placement of blindly inserted gastric tubes. Current placement facilitation techniques are perpetuated through anecdotal experience and technique variability warrants further study.

Conclusion

In the absence of aspiration risk factors or the need for surgical decompression in ASA classification I & II patients, a moratorium should be instituted on the elective use of gastric tubes.

A Case Report of Poisoning Caused by Incorrect Use of Salvia

Patient: Female, 54

Final Diagnosis: Salvia intoxication

Symptoms: Frequent nausea

Medication: Thyroxine

Clinical Procedure: —

Specialty: Hematology

Methods to determine the internal length of nasogastric feeding tubes: An integrative review

OBJECTIVES

Improper placement of nasogastric tube used for feeding may lead to serious complications, including death of the patient. There are several different methods used to determine the appropriate length of nasogastric tube for optimal placement in adults. This integrative review of the literature was designed to identify the most accurate method to determine the internal length of nasogastric feeding tube in adults.

DESIGN

An integrative review of the research literature (1979-2015) using the population-intervention-comparison-outcomes strategy.

DATA SOURCES

The literature search included the Cumulative Index to Nursing and Allied Health Literature (CINAHL), Cochrane Library, Joanna Briggs, PubMed (MEDLINE), SCOPUS, and Web of Science electronic databases.

REVIEW METHODS

Two researchers evaluated the literature to determine if an article met inclusion and exclusion criteria. The quality of the evidence was assessed using the Johns Hopkins Strength of the Evidence critical appraisal tool.

RESULTS

Twenty studies, published between 1979 and 2014, met inclusion criteria. Of these, nine articles were expert opinion, seven were original research, three were review articles, and one was a guideline. Despite seven original research papers being found, only five reports were about the methods to determine the internal length of nasogastric feeding tube in adults. The literature suggests that four different methods for measuring the tube length are likely to result in proper placement of the tip of the tube in the stomach and all side ports inside it: [nose-to-ear-to-xiphisternum - 50]cm/2+50cm]; [gender-weight and nose-umbilicus-flat]; [xiphisternum-to-ear-to-nose+10cm]; [earlobe to xiphisternum to umbilicus - tip of the nose to earlobe]. Four studies found nose-to-ear-to-xiphisternum was most likely to result in a tube that is positioned incorrectly, either ending in the esophagus, in the stomach but too close to the esophagus, or too far into the stomach or duodenum.

CONCLUSIONS

The nose-to-ear-to-xiphisternum and Hanson method should no longer be taught in nursing programs or used in practice by the nurse. The [gender-weight and nose-umbilicus-flat] method has been shown to be safer.

Effects of siRNA-Mediated Knockdown of HDAC1 on the Biological Behavior of Esophageal Carcinoma Cell Lines

BACKGROUND HDAC1 has been shown to be closely associated with the occurrence of tumors. We aimed to investigate the effects of siRNA-mediated HDAC1 knockdown on the biological behavior of esophageal carcinoma cell lines. MATERIAL AND METHODS HDAC1 expression in esophageal cancer cell lines TE-1, Eca109, and EC9706 was compared by Western blot analysis. These cells were transfected with siRNA-HDAC1 and cell proliferation was evaluated by MTT assay to select the optimum cell line for subsequent experiments. The effects of siRNA-HDAC1 on the migration and invasion of the selected cell line were assessed by transwell assay. The expression of cell cycle-related proteins cyclinD1, p21 and p27, and epithelial-mesenchymal transition (EMT)-related protein zonula occludens-1 (ZO-1), E-cadherin and vimentin was determined by Western blot analysis. RESULTS HDAC1 expression in TE-1, Eca109 and EC9706 cells was significantly higher compared with normal esophageal cell line HEEC (P<0.01). MTT assay, Western blot and RT-PCR analyses demonstrated that the inhibitory effects of siRNA on HDAC1 expression and cell viability in TE-1 cells were the highest among all cell lines, which was therefore used in subsequent experiments. After TE-1 cells were transfected with siRNA-HDAC1, their migration and invasion were significantly lower compared with the controls (P<0.01). CyclinD1 and vimentin expression was significantly lower compared with the controls (P<0.01), whereas the expression of p21, p27, ZO-1 and E-cadherin was significantly higher (P<0.01). CONCLUSIONS The siRNA-mediated HDAC1 knockdown significantly inhibited the proliferation, migration and invasion of TE-1 cells probably by regulating the expression of cell cycle- and EMT-related proteins.

A Case of Eosinophilic Gastroenteritis Forming a Rigid Chamber Mimicking Giant Duodenal Ulcer on Computed Tomography Imaging

Patient: Female, 67

Final Diagnosis: Eosinophilic gastroenteritis

Symptoms: Abdominal distension • abdominal pain • chronic diarrhea

Medication: —

Clinical Procedure: CT

Specialty: Gastroenterology and Hepatology

Gossypiboma Mimicking a Mesenchymal Tumor: A Report of a Rare Case

Patient: Female, 62

Final Diagnosis: Gossypiboma

Symptoms: Abdominal discomfort

Medication: —

Clinical Procedure: Surgery

Specialty: Surgery

The Forgotten One: Lemierre's Syndrome Due to Gram-Negative Rods Prevotella Bacteremia

Patient: Male, 22

Final Diagnosis: Lemierre’s syndrome

Symptoms: Dyspnea • chest pain • swelling

Medication: —

Clinical Procedure: Thoracentesis

Specialty: Infectious Diseases

A Life-Threatening Mediastinal Hematoma After Central Venous Port System Implantation

BACKGROUND

We report a case of surgical central venous port system implantation using Seldinger's technique with a life-threatening mediastinal hematoma due to the perforation of the superior vena cava.

CASE REPORT

A 68-year-old woman was admitted to our institution for port implantation. Open access to the cephalic vein and 2 punctures of the right subclavian vein were unsuccessful. Finally, the port catheter could be placed into the superior vena cava using Seldinger's technique. As blood aspiration via the port catheter was not possible, fluoroscopy was performed, revealing mediastinal contrast extravasation without contrasting the venous system. A new port system could be placed in the correct position without difficulties. After extubation, the patient presented with severe respiratory distress and required consecutive cardiopulmonary resuscitation and reintubation. The CT scan showed a significant hematoma in the lower neck and posterior mediastinum with tracheal compression. We assumed a perforation of the superior vena cava with the tip of the guidewire using Seldinger's technique. Long-term intensive treatment with prolonged ventilation and tracheotomy was necessary. The port system had to be subsequently explanted due to infection.

CONCLUSIONS

Mediastinal hematoma is a rare but life-threatening complication associated with central venous catheterization using Seldinger's technique. Perforation occurs most often during central venous catheterization in critical care. Mediastinal hematoma is an example of a mechanical complication occurring after central venous catheterization, which has been described only a few times in the literature to date. This case highlights the importance of awareness of possible, rare, life-threatening complications during port implantation, mostly performed in multimorbid patients by surgeons in training.