Common Causes of No Return During Gastric Lavage
The most common causes of no fluid return during gastric lavage include tube malposition, tube obstruction, or inadequate insertion depth, which require immediate assessment and correction to prevent complications.
Potential Causes of Failed Gastric Lavage Return
Tube Position Issues
- Malposition of the tube - The tube may not be properly positioned in the stomach, which occurs in up to 50% of pediatric cases even when auscultation suggests proper placement 1
- Excessive tube insertion - Stretching the stomach inferiorly towards the pelvis can prevent proper fluid return 1
- Inadequate insertion depth - The tube may not be inserted deeply enough to reach the gastric contents 1
Tube Obstruction Issues
- Clogging of the tube - The tube may be obstructed by thick gastric contents, food particles, or medications 2
- Kinking of the tube - The tube may be kinked or twisted within the gastrointestinal tract 3
- Tube impaction - The tube may become impacted against the gastric wall or in the esophagus 3
Gastric Anatomy Issues
- Buried bumper syndrome (BBS) - If performing lavage through a gastrostomy tube, the internal fixation device may have migrated into the gastric wall 4
- Gastric mucosa 'pocket' - The gastric mucosa may have grown over and around the bumper of a gastrostomy tube 4
- Pressure issues - Excessive pressure between internal and external bolsters of gastrostomy tubes can lead to complications 4
Assessment and Troubleshooting Algorithm
Step 1: Check Tube Position
- Verify tube placement radiographically, as clinical tests like auscultation fail to detect malpositioned tubes 1
- For pediatric patients, consider using adapted formulas for proper insertion depth:
- Orogastric: 9.7 cm + (0.226 × patient length in cm)
- Nasogastric: 8 cm + (0.252 × patient length in cm) 1
Step 2: Address Tube Obstruction
- Attempt gentle flushing with small amounts of fluid to clear potential obstructions 5
- If using a gastrostomy tube, check for excessive tension between internal and external bolsters 4
- For gastrostomy tubes, ensure the tube is advanced into the stomach for at least 2-3 cm (ideally 5-10 cm) 4
Step 3: Reposition Patient and Tube
- Change the patient's position to help mobilize gastric contents 6
- Gently rotate or reposition the tube, but avoid excessive manipulation 4
- For gastrostomy tubes, avoid rotation if a jejunal extension is present 4
Special Considerations and Complications
For Gastrostomy Tubes
- Check for buried bumper syndrome - Signs include difficulty mobilizing the tube, leakage around insertion site, and resistance when administering fluids 4
- Assess proper tension - The distance between bolsters should not be too loose or too restrictive 4
- Consider internal drainage options - For persistent issues, double pigtail stents may be needed for internal drainage 7
Potential Complications to Monitor
- Aspiration - Occurs in 0.3-1.0% of cases during gastric procedures and carries risks of hypoxia and hypotension 4
- Perforation - Complete laceration of the stomach occurs in 0.5-1.3% of cases 4
- Cardiac arrest - Has been reported as a serious complication of improperly performed gastric lavage 6
Important Caveats
- Gastric lavage should not be performed routinely for poisoned patients due to lack of evidence for benefit and potential for serious complications 2
- When lavage is indicated, it should only be performed by individuals with proper training and expertise 2
- Proper airway protection is essential in patients with reduced consciousness 6
- Use appropriate volumes of fluid for each cycle to avoid complications 6