Is a nasogastric (NG) tube really needed for management of small bowel obstruction (SBO)? NG tube placement is one of my least favorite ED procedures. I therefore find myself hesitating every time surgery requests one, but what is the evidence behind it?
Surprisingly, there is little data and no randomized control trials on the use of NG tubes in SBO. A chart review in 2013 looked at 290 patients admitted with SBO. 20% of those 290 patients had a NG tube placed. They found that ⅔ of these patients were managed non-operatively, irrespective of NG tube placement. In addition, decompression with an NG tube was not found to be associated with decreased bowel ischemia or need for surgery. Use of an NG tube was actually found to be associated with worse outcomes, such as increased length of hospital stay, higher complication rate, and longer time to resolution.
Part of the reason that I dislike this procedure is the apparent discomfort we cause when placing them. Patients routinely rate it as one of the most painful procedures performed in the ED. We attempt to decrease pain with anesthetics, even though many ED physicians do not believe them to be effective. A RCT was done assessing the use of surgical lubricant versus topical lidocaine and phenylephrine for the nose with tetracaine and benzocaine spray for the throat. Patients reported a significant decrease in discomfort when providers used vasoconstrictors and topical anesthetics compared to surgical lubricant.
However, there are some cases where NG tubes may be indicated. Patients who are vomiting after antiemetics or have a significantly distended stomach may benefit. Rather than placing them on all patients diagnosed with an SBO, we should select patients for this procedure based on their symptoms.
Thanks for reading!
Ariella
Resources:
Fonseca AL, Schuster KM, Maung AA, Kaplan LJ, Davis KA. Routine nasogastric decompression in small bowel obstruction: is it really necessary? Am Surg. 2013 Apr;79(4):422-8. PMID: 23574854
Paradis M. Towards evidence-based emergency medicine: Best BETs from the Manchester Royal Infirmary. BET 1: Is routine nasogastric decompression indicated in small bowel occlusion? Emerg Med J. 2014 Mar;31(3):248-9. doi: 10.1136/emermed-2014-203617.1. PMID: 24532357