8 Gastrointestinal Procedures and Devices

Question 1

Role of nasogastric aspiration in GI bleeding

Answer 1

1. Localization of bleeding into the upper GI
2. Assessment of rate of hemorrhage

Also:
When the clinical picture suggets a slower rate of bleeding, such as with coffee-ground emesis or blood-streaked emesis, the need for NG aspiration is less clear because less sensitive methods of assessing the rate of hemorrhage, such as observation of spontaneous bleeding, hemodynamic assessment, and serial hematocrit measurement, are often adequate.

Question 2

Role of NG aspiration in patietns without hematemesis

Answer 2

NG aspiration lacks sensitivity to detect an upper GI source in patients without hematemesis

Duodenal source of bleeding are beyond the reach of the NG tube.

Most patients with melena have an upper GI source and require upper endoscopy regardless of the results of NG aspiration.

Question 3

Role of NG aspiration in severe, ongoing rectal bleeding with instability

Answer 3

NG aspiration is relatively useful because severe upper GI bleeding is generally easier to stop than severe lower GI bleeding

Question 4

The main morbidity from NG aspiration

Answer 4

is probably related to pain, followed by epistaxis, both of which can be minimized by good technique

Question 5

Optimal positioning for NGT insertion

Answer 5

With the patient seated upright with the neck slightly flexed

Question 6

Premedications in NGT insertion

Answer 6

1. Topical application of anesthetic can reduce the pain of the procedure, and a vasoconstrictor can shrink the turbinates, creating a larger nasal opening
2. One option is to mix 4% lidocaine wit oxymetazoline and instill this solution using a nasal atomizer
3. Premedication with IV metoclopramide, in adults, or lingual 24% to 25% sucrose, in infants, may also decrease pain
4. Also, in adults, premedication with a small dose of midazolam (2 mg) improves pain relief compared with topical anesthesia alone

Question 7

direction of NGT insertion

Answer 7

Direct the tube posteriorly, not superiorly, and it should naturally bend inferiorly toward the glottis.

Resistance is expected at the level of the glottis. At this point, have the patient take a drink of water, and advance the tube at the time of swallowing. This step minimizes the potential for false passage at the level of the glottis

Question 8

In patients with endotracheal intubation, what to do during NGT insertion

Answer 8

Flexing the neck of cooling the tube in ice water to stiffen it may facilitate passage

Question 9

These indicate tracheobronchial placement

Answer 9

Coughing or choking
Inability to speak
Air bubbles when proximal end of tube is placed in water

Question 10

What is this device?

Answer 10

Esophageal balloon
aka Sengstaken-Blakemore tube
- used to tamponade bleeding from esophageal varices
- has a role in cases in which endoscopy is unavailable or hemorrhage is refractory to endoscopic techniques

The patient will not be able to swallow secretions with this in place, so proximal suction, whether from a proximal port in the device or an NGT inserted proximally, will further minimize the risk of aspiraiton

Question 11

Indications for therapeutic paracentesis

Answer 11

Patients with respiratory compromise or severe pain due to tense ascites - large quantity of fluid, often greater than 5 L is removed.

Question 12

Remarks on large-volume paracentesis

Answer 12

Large-volume paracentesis (>5 L) is associated with complications such as hyponatremia, renal impairment, and encephalopathy.

Many of these patients require other treatment, including albumin infusion.

Therefore, it is generally best reserved for the admitting team or ED observation unit, except in rare cases in which pain or repiratory compromise cannot be controlled in the ED with medications or supplemental oxygen

Question 13

When to consider correcting coagulopathy and thrombocytopenia before paracentesis?

Answer 13

INR >2.5 or platelets <50,000/uL

Question 14

used to create a displaced track to the peritoneum

Answer 14

Z-track technique
- traction on the skin to create a displaced track to the peritoneum
- used to minimize the potential for infection and persistent leakage

Question 15

Remarks on diagnostic paracentesis

Answer 15

Even if the goal is diagnosis, removal of 1 to 2 L is unlikely to cause complications and may provide significant symptomatic relief

Question 16

This can be placed to minimize leakage

Answer 16

A purse-string suture

Question 17

Other remarks for post-paracentesis

Answer 17

1. Recheck the patient in 30 minutes to identify persistent leakage or an increase in symptoms to suggest a complication
2. Patients with large-volume paracentesis should be monitored for hypotension for severe hours after the procedure

Question 18

Remarks on transabdominal feeding tubes

Answer 18

1. Although the techniques for the initial placement of transabdominal feeding tubes (G-tube, J-tube, gastrojejunostomy) are beyond the scope of emergency physicians, complications related to these tubes need to be recognized
2. These tubes can be placed by
   - a surgeon using open technique
   - a gastroenterologist using endoscopic technique (percutaneous endoscopic gastrostomy)
   - a radiologist with percutaneous techniques

Question 19

Technique with fewer complications

Answer 19

The radiographic technique has been associated with fewer complications than has open or endoscopically assisted placement

Question 20

How to unclog feeding tubes

Answer 20

Instill warm water or carbonated beverage (cola is most often used) and let it remain for 20 minutes.

Then attempt flushing.

Question 21

Remarks on feeding tube replacement

Answer 21

If the tube has become dislodged or fallen out, replace it as quickly as possible (within a few hours) to prevent closure of the tract.

Most tracts mature after 2 to 3 weeks. Do not attempt to replace a tube with an immature tract.

Question 22

If the size of the tube being replaced is not known, it is reasonable to start with

Answer 22

a 16- or 18-F replacement gastrostomy tube or Foley catheter

Question 23

After replacing the tube,

Answer 23

instill a 20- to 30 mL bolus of a water-soluble contrast material (e.g., diatrizoate meglumine and diatrizoate sodium solution [Gastrografin]) through the tube, and obtain a supine abdominal radiograph within 1 to 2 minutes.

The radiograph should demonstrate rugae of the stomach or flow into the small bowel .

Question 24

Remarks on jejunostomy tubes

Answer 24

1. Jejunostomy tracts are smaller, and smaller tubes are used (8- to 14-F)
2. **If a Foley catheter is used to replace a lost jejunostomy catheter, the balloon should never be inflated because it can cause a bowel obstruction or damage the jejunum.
3. The tube is lubricated, inserted into the stoma, and advanced (20 cm)*