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Three Part Question

In [patients with known oesophageal varices], is [blind placement of a nasogastric tube for diagnostic or therapeutic intervention] safe versus [no intervention]?

Clinical Scenario

A 65 years old male, with known liver cirrhosis, portal hypertension and oesophageal varices, present with hematochizia at your emergency department. Given the probability of a upper gastro-intestinal bleeding in this patient, you want to perform a diagnostic aspiration with a nasogastric tube, but wonder if the risk of triggering a variceal bleeding with the tube because of mechanic trauma really exist or if it is only a myth.

Search Strategy

The search was performed on March 24th, 2014.

A. No BestBETs review was found on this subject

B. No Cochrane review was found on this subject

C. www.clinicaltrials.org was searched for an ongoing trial on this topic. 4 trials were found to be relevant on this subject

D. MEDLINE (through PubMED)
1. "Intubation, Gastrointestinal"[Mesh] = 8189 articles were found
2. "Esophageal and Gastric Varices"[Mesh] = 11133 articles were found
3. 1 AND 2 = 70 articles were screened for relevance
4. Of those, 1 paper was found to be relevant to the question

E. EMBASE
1. nasogastric AND tube = 8,220
2. orogastric AND tube = 470
3. nasogastric AND tube OR (orogastric AND tube) = 8,612
4. varices = 22,858
5. nasogastric AND tube OR (orogastric AND tube) AND varices = 68 articles were screened for relevance
6. Of those, 1 paper was found to be relevant to the question, however it had already been found by other search strategy.

Search Outcome

1 study was found to be relevant to the question

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Lopez-Torres and Waye 1973 U.S.A.	75 patients with end-stage hepatic disease undergoing hepatic transplantation. 81% with endoscopy proven varices and 39% with previous variceal bleeding.	Retrospective observational	Acute upper gastro-intestinal bleeding	0 patients experienced upper gastro-intestinal bleeding. 0% CI [0-4.8%]	No active bleeding before placement of NG tube. Elective and emergent surgery Anesthetized patients

Comment(s)

Original concerns about blind placement of NG tube in cirrhotic patient is an expert opinion and can be traced back in the litterature to the beginning of 1970’s by Zollinger et al.[2] However, no case series nor studies ever proved this concern to be true. (2) Zollinger, R.M. and W.V. Nick, Upper-gastrointestinal tract hemorrhage. JAMA, 1970. 212(13): p. 2251-4.

Clinical Bottom Line

Even though clinical value of diagnostic NG/OG tube for gastro-intestinal bleeding remains subjet to great debate, the traditionnal teaching that blind oesophageal instrumentation using a small tube risks precipitating variceal bleeding is unproven. The risk/benefits ratio in the decision to perform such a procedure should be weighted using other clinical features (discomfort, diagnostic or therapeutic value, etc.)

References

1. Lopez-Torres, A. and J.D. Waye The safety of intubation in patients with esophageal varices Am J Dig Dis 1973. 18(12): p. 1032-4.