Should all patients with bowel perforation have a nasogastric (NG) tube inserted?

Nasogastric Tube Use in Patients with Bowel Perforation

Not all patients with bowel perforation require nasogastric tube insertion, and routine use should be avoided in favor of selective application based on specific clinical indications. 1

Evidence-Based Approach to NG Tube Use

The decision to place a nasogastric tube in patients with bowel perforation should follow a structured algorithm:

Indications for NG Tube Placement:

• Patients at high risk of regurgitation of gastric contents 1
• Presence of significant gastric distention 1
• Full stomach confirmed by clinical assessment or point-of-care ultrasound 1
• Gastric content volume >1.5 mL/kg as determined by ultrasound 1
• Patients requiring gastric decompression during rapid sequence intubation 1

Contraindications and Cautions:

• Recent history of nasal trauma or surgery
• Coagulopathy
• Basilar skull fracture
• History of recurrent aspiration with NG tube in place
• Previous esophageal surgery that may increase perforation risk 2, 3

Benefits vs. Risks Assessment

Potential Benefits:

• Decreased intragastric pressure and gastric content volume 1
• Lower likelihood and severity of emesis and pulmonary aspiration 1
• Gastric decompression in cases of significant distention

Potential Risks:

• Increased rates of fever, atelectasis, and pneumonia 1
• Pharyngolaryngitis and respiratory infections 1
• Increased gastroesophageal reflux during laparotomy 1
• Rare but serious complications including perforation of pharynx, esophagus, or stomach 2, 3
• Nasal erosions, sinusitis, and patient discomfort 1

Evidence Quality and Recommendations

The Enhanced Recovery After Surgery (ERAS) Society provides high-quality evidence (level: high) with a strong recommendation against routine postoperative nasogastric tube use in colorectal surgery 1. This is supported by a Cochrane meta-analysis of 33 trials with over 5,000 patients that found earlier return of bowel function and fewer pulmonary complications when nasogastric decompression was avoided 1.

The Society of Critical Care Medicine (2023) advises selective NG tube decompression only when benefits outweigh risks in patients undergoing rapid sequence intubation who are at high risk of regurgitation 1.

Clinical Implementation

For Emergency Department/Initial Management:

1. Assess for specific indications (gastric distention, high aspiration risk)
2. Consider point-of-care ultrasound to evaluate gastric contents 1
3. Place NG tube only if clear benefits outweigh risks
4. If placed during surgery, remove before reversal of anesthesia 1

For Surgical Management:

1. Avoid routine NG tube placement for bowel perforation repair
2. Consider temporary intraoperative placement only if needed for gastric decompression
3. Remove before completion of surgery when possible

Common Pitfalls to Avoid

• Placing NG tubes "routinely" without specific indications
• Keeping NG tubes in place longer than necessary
• Failing to monitor for complications of NG tube placement
• Not considering patient anatomy that may increase perforation risk (e.g., previous gastric bypass) 3

Research shows that routine NG decompression does not accomplish its intended goals of hastening return of bowel function, preventing pulmonary complications, or decreasing anastomotic leakage 4. In fact, patients managed without routine NG tubes have earlier return of bowel function and fewer pulmonary complications 4, 5.

In summary, the evidence strongly supports selective rather than routine use of nasogastric tubes in patients with bowel perforation, with placement decisions based on specific clinical indications rather than standard protocol.