Safety and Efficacy of Nasogastric Intubation for Gastrointestinal Bleeding After Myocardial Infarction: An Analysis of 125 Patients at Two Tertiary Cardiac Referral Hospitals

Abstract

Our purpose was to analyze risks versus benefits of nasogastric (NG) intubation for gastrointestinal (GI) bleeding performed soon after myocardial infarction (MI). While NG intubation and aspiration is relatively safe, clinically beneficial, and routinely performed in the general population for recent GI bleeding, its safety after MI is unstudied and unknown. In addition to the usual complications of NG tubes, patients status post-MI may be particularly susceptible to myocardial ischemia or cardiac arrhythmias from anxiety or discomfort during intubation. We studied NG intubation within 30 days of MI in 125 patients at two hospitals from 1986 through 2001. Indications for NG intubation included melena in 55 patients; fecal occult blood with an acute hematocrit decline, severe anemia, or sudden hypotension in 37; hematemesis in 18; bright red blood per rectum in 8; and dark red blood per rectum in 7. The intubation was performed on average 5.3 +/- 7.2 (SD) days after MI. NG aspiration revealed bright red blood in 38 patients, "coffee grounds"-appearing blood in 45, and clear (or bilious) fluid in 42. Among 114 of the patients undergoing esophagogastroduodenoscopy (EGD), EGD revealed the cause of bleeding in 79 (95%) of 83 patients with a grossly bloody NG aspirate versus 12 (39%) of 31 patients with a clear aspirate (P < 0.0001, OR = 31.3, OR CI = 9.4-103.1). Among 85 patients undergoing EGD within 16 hr of NG intubation, stigmata of recent hemorrhage were present in 28 (42%) of 66 with a bloody NG aspirate versus 3 (16%) of 19 with a clear aspirate (P = 0.06, OR = 3.93). Among 35 patients undergoing lower GI endoscopy, lower endoscopy revealed the cause of bleeding in 14 (56%) of 25 patients with a clear NG aspirate versus 1 (10%) of 10 patients with a grossly bloody aspirate (P < 0.04, OR = 11.46, OR CI = 1.55-78.3). The two NG tube complications (epistaxis during intubation and gastric erosions from NG suctioning) were neither cardiac nor major (requiring blood transfusions). This study suggests that short-term NG intubation is relatively safe and may be beneficial and indicated for acute GI bleeding after recent MI. Aside from improving visualization at EGD, the potential benefits include providing a rational basis for the timing of endoscopy (urgent versus semielective), for prioritizing the order of endoscopy (EGD versus colonoscopy), and for avoiding or deferring endoscopy in low-yield situations (e.g., colonoscopy when the NG aspirate is bloody). These benefits may be particularly relevant in patients after recent MI due to their increased endoscopic risks.

Upper Gastrointestinal Bleeding in Oncological Patients

“…The bright red blood suggests active bleeding, while the dark red blood suggests recent bleeding. The continuous aspiration of bright red blood suggests severe active bleeding, associated with a higher rate of evidence of active bleeding and other endoscopic stigmas of recent hemorrhaging while performing an emergency UGE, as compared to a dark red aspiration or without the presence of blood [18].…”

“…The erosions are recognized as being multiple, collinear, equidistant, rounded, and relatively uniform, as well as being in the same stage of evolution [11]. In a review of 152 nasogastric catheterisms in patients with upper gastrointestinal bleeding, considering that of these, 125 had suffered an acute myocardial infarction within a period of 30 days prior to the procedure, only two (1.3%) cases presented clinically significant complications, including one case of nosebleeds and another of gastric erosion induced by the tube, both of which were treated with a blood transfusion (red blood cell concentrates), evolving with no clinical sequelae [18]. The risk of nosebleeds is reduced with the use of a correct technique, when introduced softly, with lubrification of the end of the tube, with cooperation from the patient, suspension of venous heparine therapy four hours prior to the introduction of the catheter, and avoiding the insertion when a coagulopathy is detected.…”

Nasogastric Aspiration and Lavage in Emergency Department Patients with Hematochezia or Melena Without Hematemesis

“…After the exclusions, we based our review on three studies. 15,17,18 We did not find any systematic reviews or meta-analyses on this subject. All three studies included in our review had retrospective designs.…”

“…We identified four observational studies that met our selection criteria. [15][16][17][18] We excluded one study 16 because the results of the reference standard test (EGD) was not reported in patients with negative nasogastric aspirates. Also, 18% of patients with positive nasogastric aspirates did not receive EGD.…”

“…This study defined a high-risk lesion as visualization of an active bleeding vessel, oozing vessel, or a visible vessel. Cappell 17 considered active bleeding, stigmata of recent bleeding, or obvious significant lesion on EGD as evidence of upper GI bleeding. Finally, Witting et al 18 used a combination of information obtained from reviewing the hospital discharge summary, EGD, radionucleotide scans, angiography, or surgery as the reference standard.…”