Delayed gastric perforation following nasogastric tube insertion: the pitfalls of radiographic confirmation

Background

This report describes a delayed gastric perforation from an indwelling nasogastric (NG) tube that required multidisciplinary input from critical care, radiology, general surgery and gastroenterology to diagnose and manage.

Upper gastrointestinal perforation is a rare complication of NG tube insertion.1 This case demonstrates an uncommon, but potentially life threatening, complication of an appropriately placed, checked and functioning NG tube: a delayed gastric perforation with limited signs to indicate it had occurred.

Case presentation

A man in his 70s was admitted to the intensive care unit following an out of hospital cardiac arrest. He was obese, a current smoker and his only past medical history was an intramedullary nail fixation of the femur 10 years ago. Following a collapse while at work he received immediate bystander cardiopulmonary resuscitation by colleagues followed by three shocks from paramedics prior to return of spontaneous circulation. The total low flow period was less than 20 min. In the emergency department he had a stable cardiac output, and a posterior ST-elevation infarction was confirmed on ECG. He was agitated and non-compliant therefore requiring intubation to facilitate further treatment with the NG tube inserted at this stage. Primary percutaneous coronary intervention was undertaken with successful stenting of the mid-circumflex artery. Following our standard protocol for the management of out of hospital cardiac arrest on day 3 the patient was extubated. However due to a hospital-acquired pneumonia and significant secretion burden he was re-intubated 6 hours later. On day 9 there was a dramatic increase in his oxygen requirement (fraction of inspired oxygen 0.3–0.8) with thick secretions. CT of the thorax demonstrated bibasal consolidation while incidentally revealing that the NG tube had perforated the stomach wall now lying posterior to the spleen. On examination his abdomen was soft and non-tender with some mild bilateral flank bruising. The NG tube, placed on admission without complication and checked in accordance with National Patient Safety Agency (NPSA) guidance (figure 1), had been secured at 60 cm since insertion and had not been replaced or migrated. It had been used for 9 days without complication. Aspirates obtained from the NG had been nil until a few days prior to the scan when some blood stained secretions were aspirated. A chest X-ray undertaken the day before the CT is included (figure 2).

Figure 1

Post insertion chest X-ray showing National Patient Safety Agency (NPSA) features of a correctly placed nasogastric (NG) tube. Arrows show the NG following contour of oesophagus; bisecting the carina; crossing the diaphragm at the midline; and the tip visible below the left hemidiaphragm.

Figure 2

Chest X-ray on the day preceding the CT scan without clear evidence of the nasogastric (NG) position.

Investigations

A further CT of the abdomen and pelvis was requested (figure 3A–C). This was undertaken after a 250 mL bolus of water-soluble contrast (Gastrografin) had been administered through the NG tube. The scan confirmed that the NG tube had perforated through the posterior wall of the fundus of the stomach. The tip of the tube lay posterior to the spleen with visible extragastric contrast and a large perisplenic hyperdense collection with locules of air.

Figure 3

CT scan showing the nasogastric (NG) tip perforating through the posterior wall of the fundus of the stomach and the tip of the NG tube sitting behind the spleen.

Treatment

A multispecialty discussion with gastroenterologists, general surgeons and the intensive care teams deliberated whether removal and surgical or endoscopic repair of the perforation would offer the safest approach. As there were no signs of peritonitis or systemic sepsis, the risks of an interventional approach were felt to be unnecessarily high following the recent cardiac arrest and ongoing dual antiplatelet therapy following recent stent insertion. A conservative approach was undertaken with simple removal of the NG tube, acid suppression with a proton pump inhibitor, antimicrobial and antifungal cover and total parenteral nutrition.

After the NG tube was removed inspection of the tip showed a small amount of blood and no obvious defect. It was replaced with a Ryles tube.

Outcome and follow-up

Forty-eight hours after NG tube removal there had been a reduction in oxygen and vasopressor usage requirements, the abdomen remained soft and inflammatory markers were improving (WCC 62.6 to 20.6 × 10⁹/ L and CRP 110 to 71 mg/L). A further CT showed only a very small increase in the size of the collection (1.7 cm × 12.7 cm × 12.9 cm vs 2.4 cm × 14.1 cm × 13.8 cm previously), and percutaneous drainage was not thought necessary after further review with the radiology and surgical teams.

Unfortunately the patient then developed a large deep vein thrombosis became acutely hypotensive and hypoxaemic with bedside echocardiography demonstrating a massive right atrial thrombus and dilated right ventricle, indicating probable pulmonary embolus. Life sustaining treatment was withdrawn after multidisciplinary discussion with the cardiology team.