The Pointy End
Answer: D
This man presents on the relatively stable side the spectrum of upper GI bleeding.
In a recent meta-analysis, Srygley et al quantify historical and physical factors making upper GI bleed more likely: prior history of upper GI bleed (LR: 6.2; 95% CI: 2.8 to 14.0); history of passing black stool (LR range: 5.1 to 5.9); melena on exam (LR: 25; 95% CI: 4 to 174); and coffee-ground emesis (LR: 9.6; 95% CI: 4.0 to 23.0).
This begs the question, who needs an NGT when the clinical diagnosis is made?
The problem is the poor performance of NGT aspirate as a diagnostic test. In high-risk proven lesions, there is a 15% false negative rate (A). Conversely, a negative aspirate cannot rule out an upper GI bleed due to its poor sensitivity (42%).
Well, then we need to risk stratify this patient to know if he needs endoscopy now, right?
In a retrospective analysis, Huang et al found that performing NGT did prompt faster endoscopy than in those without NGT, but there was no difference in mortality, length of hospital stay, surgery, or transfusion (B).
A bloody NGT aspirate cannot determine if the bleeding is ongoing or if it has stopped. The old-fashioned practice to “lavage until clear” to prove no ongoing bleeding is often contradicted by findings at endoscopy.
In 2012, the American Society of Gastroenterology published guidelines on upper GI bleeding and states: “Nasogastric or orogastric lavage is not required in patients with UGIB for diagnosis, prognosis, visualization, or therapeutic effect.” (A,B,C)
So what? Just drop an NGT – it’s no big deal, right?
NGT has been rated as the most painful and distressful procedure done in the ED (Singer et al).
Complications include: perforation, bronchial intubation, bleeding, reflux and aspiration (due to keeping lower esophageal sphincter open), and nasogastric tube syndrome (post-cricoid ulceration affecting the cricoarytenoid muscles, causing vocal cord abduction paralysis and upper airway obstruction).
If you must perform NGT insertion (hopefully for a better indication such as small bowel obstruction, in which NGT does improve symptoms and helps to avoid surgery), a few tips:
● Nebulized concentrated lidocaine (e.g. 3 mL of 4% lidocaine)
● Phenylephrine to the naris, then viscous lidocaine gel
● Route the end of the NGT along the groove of an oropharyngeal airway, then place in ice water bath for a
full minute – this will harden the tip temporarily in a “hook” that will guide placement
● Coach your patient as he sips on water (closes epiglottis and helps to prevent tracheal intubation)
Bottom Line:
● Hemodynamically unstable patients (based on pulse, pressure, hemoglobin, other clinical factors /
judgement) need emergent endoscopy, regardless of any test (e.g. NGT)
● In hemodynamically stable patients with a clinical diagnosis of upper GI bleed (melena, coffee-ground
emesis, hematemesis), NGT does not add to the confirmation of the diagnosis, and has no role in deciding
when to scope (due to its poor performance as a test).
● NGT placement is not a negligible or benign test, and we should not subject our patients to this to
'prove’ something to consulting or admitting services.
References
Huang ES, Karsan S, Kanwal F, Singh I, Makhani M, Spiegel BM. Impact of nasogastric lavage on outcomes in acute GI bleeding. Gastrointest Endosc. 2011; 74(5):971-80.
Laine L, Jensen DM. ACG Practice Guideline: Management of Patients With Ulcer Bleeding. Am J Gastroenterol. 2012; 107:345–360.
Singer AJ, Richman PB, Kowalska A, et al. Comparison of patient and practitioner assessments of pain from commonly performed emergency department procedures. Ann Emerg Med.1999;33:652–8.
Srygley FD, Gerardo CJ, Tran T, Fisher DA. Does This Patient Have a Severe Upper Gastrointestinal Bleed? (Rational Clinical Exam Series). JAMA. 2012;307(10):1072-1079.
This man presents on the relatively stable side the spectrum of upper GI bleeding.
In a recent meta-analysis, Srygley et al quantify historical and physical factors making upper GI bleed more likely: prior history of upper GI bleed (LR: 6.2; 95% CI: 2.8 to 14.0); history of passing black stool (LR range: 5.1 to 5.9); melena on exam (LR: 25; 95% CI: 4 to 174); and coffee-ground emesis (LR: 9.6; 95% CI: 4.0 to 23.0).
This begs the question, who needs an NGT when the clinical diagnosis is made?
The problem is the poor performance of NGT aspirate as a diagnostic test. In high-risk proven lesions, there is a 15% false negative rate (A). Conversely, a negative aspirate cannot rule out an upper GI bleed due to its poor sensitivity (42%).
Well, then we need to risk stratify this patient to know if he needs endoscopy now, right?
In a retrospective analysis, Huang et al found that performing NGT did prompt faster endoscopy than in those without NGT, but there was no difference in mortality, length of hospital stay, surgery, or transfusion (B).
A bloody NGT aspirate cannot determine if the bleeding is ongoing or if it has stopped. The old-fashioned practice to “lavage until clear” to prove no ongoing bleeding is often contradicted by findings at endoscopy.
In 2012, the American Society of Gastroenterology published guidelines on upper GI bleeding and states: “Nasogastric or orogastric lavage is not required in patients with UGIB for diagnosis, prognosis, visualization, or therapeutic effect.” (A,B,C)
So what? Just drop an NGT – it’s no big deal, right?
NGT has been rated as the most painful and distressful procedure done in the ED (Singer et al).
Complications include: perforation, bronchial intubation, bleeding, reflux and aspiration (due to keeping lower esophageal sphincter open), and nasogastric tube syndrome (post-cricoid ulceration affecting the cricoarytenoid muscles, causing vocal cord abduction paralysis and upper airway obstruction).
If you must perform NGT insertion (hopefully for a better indication such as small bowel obstruction, in which NGT does improve symptoms and helps to avoid surgery), a few tips:
● Nebulized concentrated lidocaine (e.g. 3 mL of 4% lidocaine)
● Phenylephrine to the naris, then viscous lidocaine gel
● Route the end of the NGT along the groove of an oropharyngeal airway, then place in ice water bath for a
full minute – this will harden the tip temporarily in a “hook” that will guide placement
● Coach your patient as he sips on water (closes epiglottis and helps to prevent tracheal intubation)
Bottom Line:
● Hemodynamically unstable patients (based on pulse, pressure, hemoglobin, other clinical factors /
judgement) need emergent endoscopy, regardless of any test (e.g. NGT)
● In hemodynamically stable patients with a clinical diagnosis of upper GI bleed (melena, coffee-ground
emesis, hematemesis), NGT does not add to the confirmation of the diagnosis, and has no role in deciding
when to scope (due to its poor performance as a test).
● NGT placement is not a negligible or benign test, and we should not subject our patients to this to
'prove’ something to consulting or admitting services.
References
Huang ES, Karsan S, Kanwal F, Singh I, Makhani M, Spiegel BM. Impact of nasogastric lavage on outcomes in acute GI bleeding. Gastrointest Endosc. 2011; 74(5):971-80.
Laine L, Jensen DM. ACG Practice Guideline: Management of Patients With Ulcer Bleeding. Am J Gastroenterol. 2012; 107:345–360.
Singer AJ, Richman PB, Kowalska A, et al. Comparison of patient and practitioner assessments of pain from commonly performed emergency department procedures. Ann Emerg Med.1999;33:652–8.
Srygley FD, Gerardo CJ, Tran T, Fisher DA. Does This Patient Have a Severe Upper Gastrointestinal Bleed? (Rational Clinical Exam Series). JAMA. 2012;307(10):1072-1079.