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.
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References
Aljebreen AM, Fallone CA, Barkun AN: Nasogastric aspirate predicts high-risk endoscopic lesions in patients with acute upper-GI bleeding. Gastrointest Endosc 59:172–178, 2004
Perng CL, Lin HJ, Chen CJ, Lee FY, Lee SD, Lee CH: Characteristics of patients with bleeding peptic ulcer requiring emergency endoscopy and aggressive treatment. Am J Gastroenterol 89:1811–1814, 1994
Luk GD, Bynum TE, Hendrix TR: Gastric aspiration in localization of gastrointestinal hemorrhage. JAMA 241:576–578, 1979
Lee SD, Kearney DJ: A randomized controlled trial of gastric lavage prior to endoscopy for acute upper gastrointestinal bleeding. J Clin Gastroenterol 38:861–865, 2004
Kupfer Y, Cappell MS, Tessler S: Acute gastrointestinal bleeding in the intensive care unit. Gastroenterol Clin North Am 29:275–307, 2000
Boyes RJ, Kruse JA: Nasogastric and nasoenteral intubation. Crit Care Clin 8:865–878, 1992
Cappell MS, Scarpa PJ, Nadler S, Miller SH: Complications of nasoenteral tubes: Intragastric tube knotting and intragastric tube breakage. J Clin Gastroenterol 14:144–147, 1992
Levy H: Nasogastric and nasoenteric feeding tubes. Gastrointest Endosc Clin N Am 8:529–549, 1998
Cappell MS: Gastrointestinal bleeding associated with myocardial infarction. Gastroenterol Clin North Am 29:423–444, 2000
Cappell MS: Gastrointestinal endoscopy in high-risk patients. Dig Dis 14:228–244, 1996
Cappell MS, Iacovone FM Jr: Safety and efficacy of esophagogastroduodenoscopy after myocardial infarction. Am J Med 106:29–35, 1999
Bhatti N, Amoateng-Adjepong Y, Qamar A, Manthous CA: Myocardial infarction in critically ill patients presenting with gastrointestinal hemorrhage: Retrospective analysis of risks and outcomes. Chest 114:1137–1142, 1998
Cappell MS: A study of the syndrome of simultaneous acute upper gastrointestinal bleeding and myocardial infarction in 36 patients. Am J Gastroenterol 90:1444–1449, 1995
Colleran JA, Papademetriou V, Narayan P, et al.: Electrocardiographic abnormalities suggestive of myocardial ischemia during upper gastrointestinal bleeding. Am J Cardiol 75:312–314, 1995
Emenike E, Srivastava S, Amoateng-Adjepong Y, et al.: Myocardial infarction complicating gastrointestinal hemorrhage. Mayo Clin Proc 74:235–241, 1999
Choudari CP, Rajgopal C, Palmer KR: Acute gastrointestinal haemorrhage in anticoagulated patients: Diagnoses and response to endoscopic treatment. Gut 35:464–466, 1994
van Es RF, Jonker JJ, Verheught FW, et al.: Aspirin and coumadin after acute coronary syndromes (the ASPECT-2 Study): A randomised controlled trial. Lancet 360:109–113, 2002
Cuellar RE, Gavaler JS, Alexander JA, Brouillette DE, Chien MC, Yoo YK, Rabinovitz M, Stone BG, Van Thiel DH: Gastrointestinal tract hemorrhage: The value of a nasogastric aspirate. Arch Intern Med 150:1381–1384, 1990
Fleiss JL: Statistical Methods for Rates and Proportions. Ed 2. New York, John Wiley & Sons, 1981
Fang J, Alderman MH: Dissociation of hospitalization and mortality trends for myocardial infarction in the United States from 1988 to 1997. Am J Med 113:208–214, 2002
Greene JF Jr, Sawicki JE, Doyle WF: Gastric ulceration: A complication of double-lumen nasogastric tubes. JAMA 224:338–339, 1973
Cappell MS: Safety of push enteroscopy after recent myocardial infarction. Dig Dis Sci 49:509–513, 2004
Cappell MS: The safety and clinical utility of esophagogastroduodenoscopy for acute gastrointestinal bleeding after myocardial infarction: A six-year study of 42 endoscopies in 34 consecutive patients at two university teaching hospitals. Am J Gastroenterol 88:344–350, 1993
Cappell MS: Endoscopic retrograde cholangiopancreatography with endoscopic sphincterotomy for symptomatic choledocholithiasis after recent myocardial infarction. Am J Gastroenterol 91:1827–1831, 1996
Cappell MS, Iacovone FA: The safety and efficacy of percutaneous endoscopic gastrostomy after recent myocardial infarction: A study of 28 patients and 40 controls at four university teaching hospitals. Am J Gastroenterol 91:1599–1603, 1996
Lee JG, Krucoff MW, Brazer SR: Periprocedural myocardial ischemia in patients with severe symptomatic coronary artery disease undergoing endoscopy: Prevalence and risk factors. Am J Med 99:270–275, 1995
Montalvo RD, Lee M: Risks of upper gastrointestinal endoscopy after non-Q wave myocardial infarction [letter]. Endoscopy 28:329, 1996
Rahmin MG, Tighe M, Jacobson IM: Safety of ERCP during an acute MI [letter]. Am J Gastroenterol 90:518–519, 1995
Rourk RM, Caldwell SH, Barritt AS 3rd, McCallum RW: Endoscopy for gastrointestinal bleeding after acute myocardial infarction. Va Med Q 121:246–248, 1994
Wilcox CM, Faibicher M, Wenger NK, Shalek KA: Prevalence of silent myocardial ischemia and arrhythmias in patients with coronary heart disease undergoing gastrointestinal tract endoscopic procedures. Arch Intern Med 153:2325–2330, 1993
Hughes RK, Wootton DG: Gastric sump drainage with a water seal monitor. Surgery 61:192–195, 1967
Cappell MS: Risks versus benefits of flexible sigmoidoscopy after myocardial infarction: An analysis of 78 study patients at three medical centers. Am J Med 116:707–710, 2004
Cappell MS: Safety and clinical efficacy of flexible sigmoidoscopy and colonoscopy for gastrointestinal bleeding after myocardial infarction: A six year study of 18 consecutive lower endoscopies at two university teaching hospitals. Dig Dis Sci 39:473–480, 1994
Cappell MS: Risks versus benefits of colonoscopy after myocardial infarction: An analysis of 100 study patients and 100 controls at two tertiary cardiac referral hospitals. Gastrointest Endosc 60:901–909, 2004
Chalasani N, Clark WS, Wilcox CM: Blood urea nitrogen to creatinine concentration in gastrointestinal bleeding: a reappraisal. Am J Gastroenterol 92:1796–1799, 1997
Kovacs TO, Jensen DM: Recent advances in the endoscopic diagnosis and therapy of upper gastrointestinal, small intestinal, and colonic bleeding. Med Clin North Am 86:1319–1356, 2002
Coffin B, Pocard M, Panis Y, Riche F, Laine MJ, Bitoun A, Lemann M, Bouhnik Y, Valleur P, Groupe des endoscopistes de garde a l'AP-HP: Erythromycin improves the quality of EGD in patients with acute upper GI bleeding: a randomized controlled study. Gastrointest Endosc 56:174–179, 2002
Leung FW: The venerable nasogastric tube. Gastrointest Endosc 59:255–260, 2004
Gilbert DA, Silverstein FE, Tedesco FJ, Buenger NK, Persing J: The national ASGE survey on upper gastrointestinal bleeding. III. Endoscopy in upper gastrointestinal bleeding. Gastrointest Endosc 27:94–102, 1981
Blackstone MO, Kirsner JB: Establishing the site of gastrointestinal bleeding [editorial]. JAMA 241:599, 1979
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Cappell, M.S. Safety and Efficacy of Nasogastric Intubation for Gastrointestinal Bleeding After Myocardial Infarction: An Analysis of 125 Patients at Two Tertiary Cardiac Referral Hospitals. Dig Dis Sci 50, 2063–2070 (2005). https://doi.org/10.1007/s10620-005-3008-8
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DOI: https://doi.org/10.1007/s10620-005-3008-8