GI, Improving Outcomes, Mythbusting

SBO, NGTs, and Primum non Nocere

You just got the call from radiology that your pleasant, frail 88 year old patient has an obstruction secondary to adhesions. There is no evidence of mesenteric ischemia on CT. The patient has a normal lactate, normal wbc, is afebrile, and is not peritoneal. He vomited once on arrival 3 hours ago, but is no longer nauseated after a one time dose of 4mg Zofran. You cringe for your patient knowing what surgery is going to say when you page them.

But whats the evidence for the infamous NG tube?

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Even the guidelines for management of SBOs can not provide links for an NGT vs no NGT trial. Level of evidence for NGT? 2b. Grade of recommendation? C. “early tube decompression… may be beneficial in the initial management of non-strangulating (acute small bowel obstruction), in adjunct with fluid resuscitation and electrolytes imbalances correction.” (italics & underline placed by this blogs author)

So what is the evidence?
290 patients with SBO, NGT vs no NGT:
pneumonia and respiratory failure was significantly associated with NGT placement. Time to resolution and hospital length of stay were significantly higher in those with NGTs.

What else can you do?
Study of 128 patients with partial adhesive SBO:
IV hydration / NGT / NPO vs IV hydration / NGT / magnesium oxide PO / lactobacillus / simethicone:
76% vs 91% successful treatment without surgery. 4.2 vs 1.0 days in hospital. Similar complication and recurrence rates. (level of evidence 1b, Grade of Recommendation: A)

Study of 70 postoperative SBO with obliterative peritonitis:
TPN / NGT vs TPN / NGT / somatostatin/ dexamethasone:
29.9 vs 22.2 days to resolution. 16.7 days vs 9.9 days of NGT use. 25.8 day vs 34.9 day length of stay. Complication and relapse rates comparable.

Unless patients are profusely vomiting despite multiple rounds of anti-emetics, I try to avoid placement of NGTs. Its a miserable procedure that leads to worse outcomes. First, do no harm.

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Nonsurgical management of partial adhesive small-bowel obstruction with oral therapy: a randomized controlled trial. PMID: 16275967
Conservative treatment of early postoperative small bowel obstruction with obliterative peritonitis. PMID: 24379592

Routine nasogastric decompression in small bowel obstruction: is it really necessary? PMID: 23574854

Bologna guidelines for diagnosis and management of adhesive small bowel obstruction (ASBO): 2013 update of the evidence-based guidelines from the world society of emergency society ASBO working group. PMID: 24112637

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One thought on “SBO, NGTs, and Primum non Nocere

  1. Pingback: EM in Focus

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