What is the treatment for bleeding through a Nasogastric (NG) tube?

Management of Bleeding Through a Nasogastric (NG) Tube

The treatment for bleeding through a nasogastric tube requires immediate assessment of the bleeding source and implementation of appropriate hemostatic measures, with endoscopic evaluation being the primary intervention for most cases.

Initial Assessment and Management

• Assess hemodynamic stability and provide resuscitation if needed with intravenous fluids and blood products, maintaining hemoglobin at 70-80 g/L 1
• Consider proton pump inhibitor (PPI) administration after initial resuscitation to reduce risk of ongoing bleeding 1
• Perform urgent endoscopic evaluation within 24 hours, with earlier endoscopy for high-risk patients with hemodynamic instability 1, 2
• Do not remove the NG tube until the source of bleeding is identified, as it can help monitor ongoing bleeding 3

Diagnostic Approach

• Bloody NG aspirate requires investigation to determine the source of bleeding:
  • Bright red blood or "coffee grounds" appearance in NG aspirate strongly correlates with upper GI bleeding source (95% diagnostic yield on endoscopy) 3
  • Clear aspirate suggests lower GI source (56% diagnostic yield on lower endoscopy) 3
• Consider upper endoscopy as the first diagnostic step when blood is present in NG aspirate 2, 3

Management Based on Bleeding Source

Gastric Varices Bleeding

• For bleeding gastric varices identified on endoscopy:
  • Cyanoacrylate injection is the treatment of choice 2
  • Consider balloon-occluded retrograde transvenous obliteration (BRTO) if a gastrorenal shunt is present 2
  • Transjugular intrahepatic portosystemic shunt (TIPS) may be used when there is significant inflow from the coronary vein 2

Non-variceal Upper GI Bleeding

• For ulcers or erosions:
  • Apply endoscopic therapy (injection, thermal probes, or clips) for lesions with active bleeding or non-bleeding visible vessels 1, 2
  • Continue high-dose PPI therapy after endoscopic treatment 1
  • For refractory bleeding, consider interventional radiology (angiographic embolization) or surgery 1

Radiation-induced Bleeding

• Consider external beam radiation therapy for chronic blood loss due to gastric cancer or radiation-induced damage 2
• Formalin application may be effective for radiation-damaged tissues 2

Post-treatment Management

• After successful hemostasis:
  • Monitor for rebleeding through the NG tube 2
  • For patients with high-risk lesions (Forrest I-IIb ulcers or variceal bleeding), wait at least 48 hours after endoscopic therapy before resuming oral or enteral feeding 4
  • For low-risk lesions (Forrest IIc and III ulcers, gastritis, Mallory-Weiss tears, esophagitis, or angiodysplasia), feeding can be resumed as soon as tolerated 4

Special Considerations

• NG tube insertion should be avoided for three days after acute variceal bleeding 2
• Only fine bore tubes should be used in patients with recent variceal bleeding to minimize trauma 2
• Long-term NG tubes should be changed every 4-6 weeks, alternating nostrils to prevent complications 2
• Consider gastrostomy or jejunostomy feeding if enteral nutrition is required for more than 4-6 weeks 2

Complications to Monitor

• NG tube-related complications include nasopharyngeal discomfort, nasal erosions, sinusitis, and rarely esophageal damage 2
• Monitor for tube displacement, which occurs in approximately 25% of cases 2
• Watch for signs of rebleeding, which may require repeat endoscopic therapy 1

Prevention of Recurrent Bleeding

• In ICU patients, enteral nutrition may serve as stress ulcer prophylaxis 4
• For patients requiring antithrombotic agents, early reintroduction appears to improve outcomes after bleeding is controlled 1
• Consider timing of reintroduction of antithrombotic therapy in consultation with the service that initiated the therapy 2