52 in 52: Nasogastric tube in GI bleeds

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    52 in 52: Nasogastric tube in GI bleeds

    Article Citation: Palamidessi N, Sinert R, Falzon L, Zehtabchi S. Nasogastric aspiration and lavage in emergency department patients with hematochezia or melena without hematemesis. Acad Emerg Med. 2010 Feb;17(2):126-32. PMID: 20370741

    What we already know about the topic: Nasogastric aspiration and lavage for patients with melena or hematochezia to localize GI bleed is controversial. Supporters argue that this can further direct workup and diagnosis, while some believe that most patients will undergo upper and lower endoscopy regardless of what a nasogastric aspiration and lavage demonstrates. Nasogastric insertion can be painful and carries some complications (hemorrhage, aspiration, esophageal perforation, hemo/pneumothorax).

    Why this study is important: To assess if nasogastric aspiration and lavage of patients with melena or hematochezia without hematemesis can differentiate between an upper or lower GI bleed.

    Brief overview of the study: This was a review study. There was an extensive search of studies in which authors performed nasogastric aspiration (with or without lavage) in all patients with hematochezia or melena and performed EGD in all patients. Studies were excluded if they included patients with known or suspected variceal bleeding, hematemesis or coffee ground emesis. This review assessed for identifying upper GI bleeding and rate of complications associated with nasogastric insertion. They found only three retrospective studies that met their criteria and found that nasogastric aspiration with or without lavage has a low sensitivity and low negative likelihood ratio for upper GI bleeding.

    Limitations: The prevalence of GI bleeds in the studies ranged from 32-74%, this wide range is likely related to differences in the patient populations of the studies. One of the studies only included patients with MIs who then developed melena or BRBPR. There was a wide range of sensitivities of nasogastric aspiration and lavage for predicting upper GI bleeding, from 42-84%. Furthermore, there were varying definitions of a positive endoscopy and only one of the studies was blinded.

    Take home points: The varying results from this review appear to mean that the test value is uncertain. Updates in GI literature (guidelines from the American Society for Gastroenterology Endoscopy and American College of Gastroenterology) also believe that nasogastric tube placement is controversial. So if a consultant asks you to perform this test, ask them if it will change their management.

    Sources:

    JH Hwang, DA Fisher, T Ben-Menachem, V Chandrasekhara, K Chathadi, GA Decker, et al. The role of endoscopy in the management of acute non-variceal upper GI bleeding. Gastrointest Endosc, 75 (2012), pp. 132–138.

    L Laine, DM Jensen. Management of Patients with Ulcer Bleeding. Am J Gastroenterol 2012; 107″

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