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Three Part Question

In adults with small bowel occlusion (SBO),)] is [nasogastric decompression better than no decompression] at [improving the process and outcome of care]?

Clinical Scenario

A 55-year-old man with a history of prior abdominal surgery presents to the emergency department with nausea, abdominal distension and absence of bowel movements for 2 days. He is not vomiting. An abdominal X-ray shows signs of small bowel obstruction. You know that there are considerable safety issues in passing and confirming the correct placement of nasogastric tubes (NGT). You wonder if there is any literature supporting these of NGT in such cases, or whether the risks outweigh the benefits.

Search Strategy

Medline: 1920 to 2 December 2013 via Pubmed: ([Intubation, gastrointestinal [MeSH] AND Intestinal obstruction [MeSH] AND Small intestine [MeSH]) OR [(Small bowel obstruction OR Small intestinal occlusion OR Small bowel occlusion OR Adhesive small bowel obstruction) AND (Nasogastric tube OR Nasogastric drainage OR Nasogastric tube decompression)]

Embase <1966 to 2 December 2013 (Filters : Humans) : Small bowel obstruction AND Nasogastric decompression

Search Outcome

No best bets were found on this topic
One Cochrane review : Prophylactic nasogastric decompression after abdominal surgery

Medline and Embase searches lead to one relevant paper.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Fonseca et al, 2013 United States	290 adults admitted with adhesive or malignant small bowel occlusion from January 2005 to June 2010. 190 were managed non-operatively. 235 received NGT (of whom 87 required operative) vs 55 who received no NGT (of whom 17 required operative intervention) cases of incarcerated hernia were excluded	Retrospective chart review	Days to resolution	3.55 vs 1.67 days (p<0.001)	Selection bias related to retrospective design No reasons given for the management without NGT No mention about nausea associated with NGT placement No readmission rates given Peritonitis could have been an exclusion criteria
			Hospital length of stay	10.16 vs 3.18 days (p<0.001)
			Disposition	87/235 vs 18/55 (p=0.08)
			Incidence bowel necrosis	5 vs 1
			factors associated with NGT placement	Lack of colonic air on CT imaging OR 3.33 (p=0.011) Diabetes OR 2.60 (p=0.036)

Comment(s)

Conservative management of SBO generally includes intravenous hydration, nasogastric intubation and clinical observation. The routine use of NGT may be beneficial, but there is no randomised controlled trial to support this widespread practice. The optimal timing for NGT placement is not known. The retrospective study described above compared outcomes of patients with SBO treated conservatively with hydration and bowel rest with and without NGT. Length of stay was longer in NGT group, whereas days to resolution were shorter in the group without NGT. That study also showed an increased pneumonia rate in patients managed conservatively with a NGT. Alternatives such as long tube advanced under direct visualisation with endoscope might be more efficient in decompressing a SBO. Further studies are needed to confirm if NGT hastens recovery from a small bowel obstruction, and to assess pulmonary complication rates.

Editor Comment

NGT, nasogastric tube.

Clinical Bottom Line

There is no scientific evidence for the routine use of nasogastric tubes in adults with small bowel occlusion.

References

1. Fonseca AL, Schuster KM, Maung AA et al. Routine nasogastric decompression in small bowel obstruction: is it really necessary? The American Surgeon 2013;79:422–8.