is nasogastric tube lavage in patients with acute upper gi bleeding indicated or antiquated? 2015

Is nasogastric tube lavage in patients with

acute upper GI bleeding indicated or

antiquated?

DR. WALEED KH. S. MAHROUS

GASTROENTEROLOGY AND HEPATOLOGY

CONSULTANT

Why We Do What We Do: NG Tubes

محروس خالد Waleed Khalid Mahrous وليد

Nasogastric lavage (NGL) was once a standard initial procedure for all patients with acute gastrointestinal (GI) bleeding, but its use is now under debate.

Although some data suggest that patients with a bloody NGL are more likely to have severe bleeding, the test's presumed benefits — confirming an upper GI source of bleeding, clearing the stomach for better endoscopic visualization, and reducing the risk for aspiration — have not been tested.

Why We Do What We Do: NG Tubes

Nasogastric lavage (NGL) seems to be a logical procedure in the evaluation of patients with suspected upper GI bleeding, but does the evidence support the logic?

Most studies state that endoscopy should occur within 24 hours of presentation, but the optimal timing within the first 24 hours is unclear.

Rebleeding is the greatest predictor of mortality, and these patients benefit from aggressive, early endoscopic hemostatic therapy and/or surgery.

So what are the arguments for and against NGL?

To Lavage or Not to Lavage?

Is Nasogastric Lavage Beneficial for Acute

Gastrointestinal Bleeding ?


Nasogastric (NG) lavage

Nasogastric (NG) lavage is an intuitively logical procedure for evaluation of stable patients without hematemesis suspected of having acute upper GI bleeding.

Indeed, a bloody NG aspirate is a good predictor of finding a high-risk lesion on upper endoscopy.

Patients undergoing NG lavage for suspected upper GI bleeding found that 45% of patients with a bloody aspirate had high-risk lesions on endoscopy versus 15% of those with only a clear or bilious aspirate.

Gastrointest Endosc. 2011 Nov;74(5):981-4. doi: 10.1016/j.gie.2011.07.007.


Prediction of high-risk lesions is important because it is those patients who have the worst outcomes and in whom early endoscopic therapy would be of most benefit.

Patients undergoing endoscopic therapy for high-risk lesions will be successfully managed in 80% to 90% of cases with control of active and prevention of further GI bleeding.

Rebleeding is the greatest predictor of poor outcomes including mortality.

Gastrointest Endosc. 2011 Nov;74(5):981-4. doi: 10.1016/j.gie.2011.07.007.


Studies suggests that finding red blood in the NG lavage predicts significant association with high-risk lesions and poor outcome vs. coffee ground.

So this studies demonstrates the benefit of a NG tube in risk stratification.

This studies suggests that early identification of high risk lesions by endoscopy decrease both re-bleeding rates and requirements for surgical intervention.


Studies shows that placement of a NGT tube, even with suggestion of a lower GI bleed can help localize the source of bleeding.

Studies shows that lavage through a NG tube can help clear the stomach contents of blood, allowing a more effective procedure during endoscopy.

From an endoscopic perspective, the fundus is typically the area of the stomach most likely to be obscured by retained blood in any bleeding scenario.


So, there is good evidence demonstrating that positive NG lavage tends to identify the presence of high-risk lesions found on subsequent endoscopy.

There is also evidence that endoscopic treatment of high-risk lesions decreases rebleeding and mortality.

So, if NG lavage identifies high-risk lesions, and endoscopic treatment of high-risk lesions decreases mortality, then patients who undergo NG lavage for their upper GI bleeds should have lower mortality, right?!!

Conclusion

ER feel that it is both helpful to the gastroenterologist, and more importantly, beneficial for the patient to place a NG tube and perform a lavage. The following should be reported to the gastroenterologist when you call them:Was bloody material spontaneously returned

upon placement of the tube.What was the color of the material that was

lavaged, bright blood red, maroon, clear with coffee-ground specks, etc.

Conclusion

If you find evidence of bleeding, please lavage at least 1-2 liters and tell us if the gastric contents clear of the bloody contents.

If there is no evidence of blood in the gastric contents, please continue to lavage until you see bilious material returned, so the gastroenterologist can be sure that you are sampling contents beyond the pylorus, a common site of peptic ulcers.

Can We Stop Placing NG Tubes?Can I simply avoid this procedure?


Can We Stop Placing NG Tubes?

A negative NG lavage in an unstable patient with suspected Upper GI bleed does not rule out a bleed passed a closed pyloric sphincter, and a positive NG lavage (that clears) in a stable patient does not warrant more urgent EGD than an unstable patient.

It is common in my experience for GI docs to use lack of NGT, or negative or equivocal lavages as a way of delaying consultation till the morning.


Incidentally, it is usually the least experienced member of the team (medical student) who is given the job of passing an NGT without adequate supervision.


How good a diagnostic test is an NG tube? Usefulness and Validity of Diagnostic Nasogastric Aspiration in Patients Without Hematemesis.

Ann Emerg Med 2004 gives us a sensitivity of 42% and a specificity of 91%.

A 42% sensitivity stinks. So if you are doing this test to make sure that there is no upper GI bleeding, a negative test would not rule this out.

If you do get blood back then it is probably an upper GI bleed.

So the next obvious question is how does this change management?

One of the worst-tolerated procedures in Emergency Medicine - placement of the NG tube.

Unfortunately, when ER call GI fellow on-call for any upper GI bleeding, the first question is invariably - what did the NG lavage show?


Patients who underwent NGL were more likely to have an endoscopy and to receive it sooner than other patients.

Lavage did not affect mortality, length of hospital stay, or the need for transfusions or surgery. Bloody aspirates were associated with high-risk lesions at endoscopy.

Conclude that NGL is associated with receiving early endoscopy and might be useful in triage but does not affect clinical outcomes.


The procedure increased the likelihood of early endoscopy but not better patient outcomes, such as lower mortality.

Nasogastric tube insertion can be a traumatic experience to the patient. May traumatize the esophageal varices , mucosa and the gastric mucosa .

The trauma marks can act as confounders to the endoscopist

Comparison of patient and practitioner assessments of pain from commonly performed emergency department

procedures.

1. It is painful What they did:Prospective, observational study1,171 procedures, from the 15 most common procedures

performed in the EDPatients recorded a pain scoreWhat they found:The most painful procedure according to

patients was NG tube placement.NG tube placement was more painful than intubation,

abscess drainage, fracture reduction, and urethral catheterization.

Ann Emerg Med. 1999 Jun;33(6):652-8.

So, it has been rated the most painful procedure we perform on a patient.

There are many ways to lesson this pain like local or systemic analgesia but it still stinks for the patient.

The gagging and spitting are not great for the provider who is trying to keep the fragile patient doctor bond intact.

Comparison of patient and practitioner assessments of pain from commonly performed emergency department

procedures.

Conclusion

The most painful procedure for ED patients is NG tube placement.

Ann Emerg Med. 1999 Jun;33(6):652-8.

Erythromycin infusion or gastric lavage for upper gastrointestinal bleeding: a multicenter randomized

controlled trial.

2. NGL IS NOT the only way to get good visualization during endoscopy What they did:Prospective, randomized, multicenter study6 EDs, 253 patients with an upper GI bleed (UGIB)IV erythromycin (84 pts) vs NGT without erythromycin (85

pts) vs NGT with erythromycin (84 pts) for visualization during endoscopy

What they found:No difference in visualization between groupsNo difference in duration of endoscopic procedure,

rebleeding, need for 2nd endoscopy, number of transfused PRBCs, or mortality at 2, 7, and 30 days

Ann Emerg Med. 2011 Jun;57(6):582-9. doi: 10.1016/j.annemergmed.2011.01.001. Epub 2011 Feb 17.

Conclusion

In acute UGIB, administration of IV erythromycin provides satisfactory endoscopic visualization without need for a NGL.

Ann Emerg Med. 2011 Jun;57(6):582-9. doi: 10.1016/j.annemergmed.2011.01.001. Epub 2011 Feb 17.

Impact of nasogastric lavage on outcomes in acute GI bleeding

3. NGL DOES NOT improve mortality, length of stay, or transfusion requirements What they did:Retrospective analysis632 patients with GI bleeding to evaluate 30-day

mortality, mean hospital length of stay (LOS), and transfusion requirements.

What they found:No statistical difference in 30 day mortality, mean

LOS, or transfusion requirements.NGL was associated with earlier time to endoscopy.

Conclusion

NGL is associated with earlier performance of endoscopy, but NO difference in clinical outcomes.

The placement of a nasogastric tube should be considered in select patients who have suspected active UGIB.

The presence of bright red blood in a gastric aspirate can be useful in identifying patients with high-risk lesions, but is not as useful if coffee ground material or other findings are present without red blood.

It should be noted that the absence of blood in a gastric aspirate does not exclude the presence of active UGIB, because approximately 15% of patients with active bleeding can have a negative result for nasogastric lavage.

Because of these limitations, and the potential patient discomfort, use of a nasogastric tube remains controversial.

GASTROINTESTINAL ENDOSCOPY Volume 75, No. 6 : 2012

Nonvariceal upper gastrointestinal hemorrhage: ESGE Guideline 2015

NVUGIH – ESGE GL 2015

In distinguishing upper from lower GI bleeding, nasogastric aspiration has low sensitivity 44% , high specificity 95% .

In identifying severe UGIH, its sensitivity and specificity are 77 % and 76%, respectively .

Clinical signs and laboratory findings (e.g., hemodynamic shock and hemoglobin < 8 g/dL) compared to nasogastric aspiration/lavage, had similar ability to identify severe UGIH .


NVUGIH – ESGE GL 2015

Others have reported that nasogastric aspiration/lavage failed to assist clinicians in correctly predicting the need for endoscopic hemostasis, did not improve visualization of the stomach at endoscopy, or improve clinically relevant outcomes such as rebleeding, need for second-look endoscopy, or blood transfusion requirements.

It also should be noted that nasogastric aspiration/lavage is a very uncomfortable procedure that is not well tolerated or desired by patients.


A3. Consider placement of a nasogastric tube in selected patients because the findings may have prognostic value.

Researchers argued here

Placement of a nasogastric tube for determining treatment of patients with upper gastrointestinal bleeding may be unnecessary since almost all these patients will eventually undergo an endoscopic procedure.

We found that the clinical judgment of the clinician was just about as good as a nasogastric tube examination - and didn't cause harm to the patient," .

http://www.medpagetoday.com/Gastroenterology/GeneralGastroenterology/





"Since there is going to be an endoscopic follow-up to confirm the diagnosis and perform definitive treatment if necessary, there is no need to continue to torture our patients with nasogastric tube placement,”

Placement of nasogastric tubes cause pain and epistaxis in as many as 25% of patients undergoing the procedure; in another 10% of patients, the tube cannot be inserted due to some form of anatomic problem.

In the study ,pain, nasal bleeding, or nasogastric tube failure occurred in 35% patients assigned to that procedure.


Many patients refused to undergo the nasogastric tube placement." Those patients who refused were also followed as to their outcomes, and their clinical diagnosis turned out to be similar to the others.


FINAL THOUGHTS

So what should we say to our gastroenterology colleagues about NGL and UGIB? European Society of Gastrointestinal Endoscopy (ESGE) Guideline 2015

guidelines, and American College of Gastroenterology 2012 guidelines state NGL is not recommended in patients with UGIB for diagnosis, prognosis, visualization, or therapeutic effect . NG lavage DOES NOT help patients in the

emergency department with acute upper GI bleed and is an outdated practice.

It looks like there is no dilemma any longer.

is nasogastric tube lavage in patients with acute upper gi bleeding indicated or antiquated? 2015

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