Retract the NGT by 2 cm
The nasogastric tube should be retracted to reposition the tip back into the stomach, as tubes placed for gastric decompression in small bowel obstruction must remain in the gastric body, not advance into the duodenum. 1
Rationale for Tube Repositioning
The primary purpose of NGT placement in small bowel obstruction is gastric decompression – removing fluid and gas that accumulate proximal to the obstruction site. 2 When the tube tip migrates past the pylorus into the duodenum:
- The tube can no longer effectively decompress the stomach, as the distal side-openings are beyond the gastric contents that need drainage 3
- Post-pyloric positioning defeats the therapeutic goal in this clinical scenario, which is specifically gastric decompression for symptomatic relief of distension and vomiting 2
Optimal NGT Tip Position for Decompression
For gastric decompression purposes, the tube tip should ideally be positioned in the body of the stomach – not too short (risking esophageal placement and aspiration) and not too long (risking duodenal migration or gastric kinking). 3
- Tubes positioned in the fundus are prone to coiling or migrating back into the esophagus, with 40-80% of NG tubes becoming dislodged without proper securement 1
- Duodenal positioning (as in this case) places the tube beyond the site requiring decompression 1
Why Not Other Options?
- Advancing the tube further (option b) would worsen the problem by pushing it deeper into the duodenum or jejunum, completely negating its decompressive function 1
- Removing and replacing entirely (option d) is unnecessarily invasive when simple retraction can correct the position 1
- Leaving it unchanged (option a) fails to address the malposition and leaves the patient without effective gastric decompression 1
Post-Pyloric Tubes: A Different Indication
Post-pyloric (duodenal/jejunal) tube placement is indicated for enteral feeding, not decompression, particularly in patients at high aspiration risk or with gastroparesis. 4, 5 However, this patient requires decompression for obstruction, not feeding – making gastric positioning essential. 2
Important Caveats
- After repositioning, secure the tube properly using appropriate methods (tape or nasal bridle) to prevent re-migration, as 40-80% of NG tubes become dislodged without proper securement 1
- If both gastric decompression and post-pyloric feeding were simultaneously needed (not the case here), a dual-lumen tube or separate tubes would be required 4, 5
- Never apply suction to jejunal tubes – if the tube were intentionally post-pyloric, suction would damage jejunal mucosa and cause electrolyte imbalances 4, 5