Is a nasogastric (NG) tube used for upper gastrointestinal (GI) bleeding?

Nasogastric Tube Use in Upper GI Bleeding

Nasogastric tube placement in upper GI bleeding is optional and should be considered selectively for prognostic purposes or to clear the stomach before endoscopy, but it is not routinely recommended for all patients. 1

When to Consider NG Tube Placement

Prognostic Value

• The presence of bright red blood in NG aspirate is an independent predictor of rebleeding and poor outcomes, helping identify patients who need emergency endoscopy. 1
• Fresh red blood in the nasogastric aspirate predicts increased risk for both rebleeding and mortality. 1
• NG aspiration confirms an upper GI source when blood is present, which is particularly useful when differentiating upper from lower GI bleeding. 1, 2

Pre-Endoscopy Preparation

• Orogastric or nasogastric lavage may be helpful to clear the stomach of blood and clots before endoscopy, potentially improving visualization. 1
• This is most relevant when very early endoscopy is planned. 1

When NOT to Use NG Tube

Routine Placement Not Recommended

• Nasogastric aspiration/lavage cannot be routinely recommended as it is a painful and time-consuming procedure with no demonstrated benefit for patient outcomes. 3
• A randomized trial of 280 patients showed that NG tube placement did not improve physicians' ability to predict high-risk lesions (39% vs 35% without NG tube, p=0.002 for non-inferiority). 4
• NG tube placement was complicated by pain, nasal bleeding, or failure in 34% of patients, with no differences in rebleeding rates or mortality. 4

Poor Diagnostic Performance

• The sensitivity of NG aspiration for predicting upper GI bleeding ranges from only 42% to 84%, with negative likelihood ratios of 0.20 to 0.62, making it inadequate for ruling out upper GI bleeding. 5
• The specificity ranges from 54% to 91%, further limiting its diagnostic utility. 5

Special Circumstances

Ventilated Patients

• In hemodynamically stable ventilated patients where active upper GI bleeding remains indeterminate, NG lavage should be considered if blood return is shown. 1
• This is NOT advised in unsedated patients due to risk of gagging, vomiting, and aerosolization. 1

Lower GI Bleeding Presentation

• When patients present with severe hematochezia and hypovolemia, an upper GI source should be considered (found in 10-15% of such patients). 1, 2
• NG lavage before upper endoscopy is warranted if there is medium to low suspicion of an upper GI source, but may be misleading if only clear fluid without bile or blood returns. 1
• Blood in the NG tube with bloody stool suggests significant upper GI bleed with brisk bleeding. 2

Better Alternatives

Risk Stratification

• Other clinical and laboratory parameters and risk scores (such as Blatchford or Rockall scores) are less invasive and equally effective for guiding patient stratification and management. 3
• Clinical predictors include age >65 years, shock, comorbidities, low hemoglobin, melena, and transfusion requirement. 1

Pre-Endoscopy Preparation

• Pre-endoscopic erythromycin infusion is a good or better alternative for improving gastric visualization compared to NG lavage. 3

Critical Pitfalls to Avoid

• Do not delay resuscitation while placing NG tube or pursuing other diagnostic tests—resuscitation with fluid and blood products always takes precedence. 2
• Do not assume NG tube placement is mandatory; the consensus panel felt diagnostic nasogastric aspiration is redundant if very early endoscopy is planned. 1
• Avoid routine NG placement in unsedated patients due to complications and lack of proven benefit. 3, 4