Nasogastric Tube Insertion for Perforated Gastric Ulcer
A nasogastric tube (NGT) should be inserted in patients with perforated gastric ulcer as it is an essential component of management for gastric decompression during the perioperative period. 1
Rationale for NGT Insertion in Perforated Gastric Ulcer
- NGT insertion serves as an adjunct to diagnostic imaging by allowing administration of water-soluble contrast to detect gastroduodenal perforation when free air is not visible on initial imaging 1
- Gastric decompression via NGT is a critical component of damage control procedures in patients with large perforations, especially when the patient is in septic shock with hemodynamic instability 1
- NGT helps prevent further gastric distention and reduces the risk of aspiration in patients who will undergo emergency surgery 2
- In cases of large duodenal defects, pyloric exclusion with gastric decompression via NGT is recommended as part of damage control surgery 1
Diagnostic Role of NGT in Perforated Gastric Ulcer
- When free air is not seen on initial imaging but perforation is still suspected, water-soluble contrast administered through an NGT can improve diagnostic sensitivity 1
- The World Journal of Emergency Surgery guidelines specifically recommend performing imaging with water-soluble contrast via NGT when perforation is suspected but not confirmed on initial imaging (weak recommendation based on very low-quality evidence, 2D) 1
Management Considerations
- NGT insertion should be performed with caution in patients with previous gastric surgery due to risk of iatrogenic perforation 3, 4
- Verification of proper NGT placement should be confirmed radiographically before initiating decompression or administering contrast 2
- For patients in septic shock from perforated peptic ulcer, damage control strategies including gastric decompression via NGT are recommended 1
Potential Complications and Precautions
- Careful insertion technique is essential as improper NGT placement can lead to complications including esophageal perforation, especially in patients with anatomical abnormalities 3, 5
- Both frontal and lateral radiographic views should be obtained to confirm proper NGT position in patients with previous gastric surgery or anatomical abnormalities 3
- NGT insertion is relatively contraindicated in patients with facial trauma or abnormal nasal anatomy 2
Duration of NGT Use
- NGT should remain in place during the perioperative period for gastric decompression 1, 6
- For patients managed non-operatively, NGT is part of the management protocol which includes nil by mouth, intravenous hydration, anti-secretory therapy, and intravenous antibiotics 1
- Extended NGT use beyond 3-4 weeks may lead to complications such as sinusitis and should be avoided 2
Special Considerations
- In elderly patients (>70 years), who are less likely to respond to conservative treatment, NGT insertion for decompression is particularly important if surgical management is planned 1
- For patients with large perforations (≥2 cm) requiring more complex surgical procedures, NGT decompression is an essential component of perioperative management 1, 6