Complicated placement of a nasogastric tube in the gastric mucosa: A case report and literature review

Abstract

Nasogastric tubes (NGTs) are commonly used in the intensive care unit (ICU) and are often inserted blindly at the bedside. Previous studies have highlighted various complications associated with NGT misplacement, including epistaxis, pneumothorax and even fatal perforations. To reduce the incidence of complications, guidelines recommend confirming the correct position of the NGT through radiography, pH testing, end-expiratory carbon dioxide monitoring, ultrasonography, etc. Herein, we present the case of a 78-year-old man who experienced sudden dyspnoea, was brought to the ICU and subsequently developed gastrointestinal bleeding following improper NGT placement. In this patient, air was rapidly injected down the NGT while auscultating for a 'whooshing sound' over the epigastrium. However, the correct position of the NGT was eventually confirmed by X-ray. Urgent upper gastrointestinal endoscopy revealed an oesophagogastric submucosal tunnelling of the NGT. This case emphasizes that auscultation may be unreliable and no longer encouraged. Additionally, various verification methods may not detect such rare complications related to NGT placement, making it necessary to focus on the emerging clinical manifestations following NGT insertion. Moreover, gaining further insight into the history of gastrointestinal diseases in patients may be beneficial. RELEVANCE TO CLINICAL PRACTICE: This case underscores the importance of noting resistance during a blind nasogastric tube (NGT) insertion in the intensive care unit (ICU). Additionally, the 'whooshing testing' for tube placement verification is not recommended. Although radiographic confirmation remains the gold standard, it may not effectively identify rare complications. Furthermore, emerging clinical signs (such as the abnormal nature of the gastrointestinal decompression drainage fluid, hypotension and anaemia) after insertion may suggest NGT misalignment. Finally, in urgent ICU settings, the patient's history of gastrointestinal disease should not be overlooked, as it can lead to complications such as gastrointestinal bleeding.

Keywords: nasogastric tube; nutrition‐nasogastric tube complications; submucosal migration.

FIGURE 1

X‐ray image obtained immediately after tube placement, demonstrating the correct insertion of the nasogastric tube into the stomach.

FIGURE 2

(a) An image captured during gastroscopy revealing the direct insertion of the nasogastric tube (NGT) under the cardia mucosa. (b) An image captured during gastroscopy showing the NGT re‐emerging from the gastric submucosa.

FIGURE 3

Images captured during gastroscopy showing the entrance (a) and exit (b) of the ‘tunnel’ after removing the nasogastric tube.

FIGURE 4

(a, b) Positron emission tomography‐computed tomography images showing increased fluorodeoxyglucose metabolism around the cardia, suggestive of inflammatory lesions. (c, d) Abdominal computed tomography images indicating the indwelling of the gastric tube at the cardia in the digestive tract lumen, with mucosal discontinuity.