What should be done for a patient experiencing vomiting one week after EGD (Esophagogastroduodenoscopy) placement?

Management of Vomiting One Week After EGD Placement

For a patient experiencing vomiting one week after EGD placement, an urgent endoscopic or fluoroscopic evaluation should be performed to determine if luminal obstruction is present, as this is likely related to a mechanical complication requiring prompt intervention. 1

Initial Assessment and Immediate Management

Step 1: Evaluate for Potential Causes

• Mechanical issues:
  • Tube malposition or migration
  • Buried bumper syndrome
  • Excessive tension between internal and external bolsters
  • Side torsion of the tube
  • Gastric outlet obstruction

Step 2: Immediate Interventions

• Stop enteral feeding until the cause is identified
• Maintain hydration with IV fluids if necessary
• Administer antiemetics such as ondansetron for symptomatic relief 2
• Check for proper tube position by examining external markings and tube mobility

Diagnostic Workup

Step 3: Imaging and Endoscopic Evaluation

• Obtain urgent endoscopic or fluoroscopic evaluation to assess tube position and patency 1
• If malposition is suspected, perform a water-soluble contrast study through the tube 3
• Consider CT imaging if contrast study is inconclusive or complications are suspected

Management Based on Findings

If Tube Malposition is Identified:

• Do not use the tube for any purpose
• Consult gastroenterology and/or surgery immediately
• Do not attempt to remove the tube without specialist input 3

If Buried Bumper Syndrome is Present:

• Identified by difficulty mobilizing the tube, leakage around insertion site, or resistance when flushing
• Requires endoscopic removal of the buried bumper and possible replacement of the tube 1

If Proper Tube Position but Persistent Vomiting:

1. Adjust tube tension:

   • Ensure 0.5-1 cm space between skin and external bolster 1
   • Avoid excessive pressure that can cause tissue compression

2. Consider pharmacological interventions:

   • Proton pump inhibitors to decrease gastric acid secretion 1
   • Prokinetic agents to improve gastric emptying if gastroparesis is suspected

3. Adjust feeding regimen:

   • Decrease rate and volume of feeds
   • Consider more dilute formula initially
   • Switch to continuous rather than bolus feeding

Prevention of Recurrence

Once Resolved:

• Proper tube maintenance:

  • Rotate the tube daily once the tract is healed (after about one week)
  • Move the tube inward at least once weekly (2-10 cm) 1
  • Check balloon volume weekly if a balloon-retention device is used 1

• Monitor for early signs of complications:

  • Difficulty mobilizing the tube
  • Leakage around insertion site
  • Resistance when flushing
  • Pain during feeding 3

Special Considerations

• If vomiting persists for >2-3 weeks, administer thiamin supplementation to prevent neurological complications 1
• For patients with severe, uncontrolled pain after stent placement, consider immediate endoscopic removal of the stent 1
• If luminal obstruction is confirmed, endoscopic lumen enhancement techniques may be required 1

Pitfalls to Avoid

• Do not assume vomiting is simply due to intolerance without proper evaluation
• Do not delay evaluation as persistent vomiting can lead to dehydration, electrolyte imbalances, and malnutrition
• Do not attempt to reposition or remove the tube without proper imaging if malposition is suspected
• Do not continue feeding through a potentially malpositioned tube as this could worsen complications

Remember that vomiting one week after EGD placement is not normal and requires prompt evaluation to prevent serious complications such as aspiration, dehydration, or tube-related injury.