Is nasogastric tube lavage in patients with acute upper GI bleeding indicated or antiquated? To Lavage or Not to Lavage?

1. Is nasogastric tube lavage
in patients with acute
upper GI bleeding
indicated or antiquated?
D R . W A L E E D K H . S .
M A H R O U S
G A S T R O E N T E R O L O G Y
A N D H E P A T O L O G Y
C O N S U L T A N T
Why We Do What We Do: NG Tubes
‫محروس‬ ‫خالد‬ ‫وليد‬Waleed Khalid Mahrous

2.  Nasogastric lavage (NGL) was once a standard
initial procedure for all patients with acute
gastrointestinal (GI) bleeding, but its use is now
under debate.
 Although some data suggest that patients with a
bloody NGL are more likely to have severe
bleeding, the test's presumed benefits — confirming
an upper GI source of bleeding, clearing the stomach
for better endoscopic visualization, and reducing the
risk for aspiration — have not been tested.
Why We Do What We Do: NG Tubes

3.  Nasogastric lavage (NGL) seems to be a logical procedure
in the evaluation of patients with suspected upper GI
bleeding, but does the evidence support the logic?
 Most studies state that endoscopy should occur within 24
hours of presentation, but the optimal timing within the
first 24 hours is unclear.
 Rebleeding is the greatest predictor of mortality,
and these patients benefit from aggressive, early
endoscopic hemostatic therapy and/or surgery.
 So what are the arguments for and
against NGL?
To Lavage or Not to Lavage?

4. ‫محروس‬ ‫خالد‬ ‫وليد‬Waleed Khalid Mahrous

5. Nasogastric (NG) lavage
Nasogastric (NG) lavage is an intuitively logical
procedure for evaluation of stable patients without
hematemesis suspected of having acute upper GI
bleeding.
Indeed, a bloody NG aspirate is a good predictor of
finding a high-risk lesion on upper endoscopy.
Patients undergoing NG lavage for suspected upper GI
bleeding found that 45% of patients with a bloody
aspirate had high-risk lesions on endoscopy versus
15% of those with only a clear or bilious aspirate.
Gastrointest Endosc. 2011 Nov;74(5):981-4. doi: 10.1016/j.gie.2011.07.007.

6. Nasogastric (NG) lavage
Prediction of high-risk lesions is important because it
is those patients who have the worst outcomes and in
whom early endoscopic therapy would be of most
benefit.
Patients undergoing endoscopic therapy for high-risk
lesions will be successfully managed in 80% to 90% of
cases with control of active and prevention of further GI
bleeding.
Rebleeding is the greatest predictor of poor
outcomes including mortality.
Gastrointest Endosc. 2011 Nov;74(5):981-4. doi: 10.1016/j.gie.2011.07.007.

7. Nasogastric (NG) lavage
Studies suggests that finding red blood in the NG
lavage predicts significant association with high-
risk lesions and poor outcome vs. coffee ground.
So this studies demonstrates the benefit of a NG tube
in risk stratification.
This studies suggests that early identification of high
risk lesions by endoscopy decrease both re-
bleeding rates and requirements for surgical
intervention.

8. Nasogastric (NG) lavage
Studies shows that placement of a NGT tube, even with
suggestion of a lower GI bleed can help localize
the source of bleeding.
Studies shows that lavage through a NG tube can help
clear the stomach contents of blood, allowing a
more effective procedure during endoscopy.
From an endoscopic perspective, the fundus is
typically the area of the stomach most likely to be
obscured by retained blood in any bleeding scenario.

9. Nasogastric (NG) lavage
So, there is good evidence demonstrating that
positive NG lavage tends to identify the presence of
high-risk lesions found on subsequent endoscopy.
There is also evidence that endoscopic treatment of high-
risk lesions decreases rebleeding and mortality.
So, if NG lavage identifies high-risk lesions, and
endoscopic treatment of high-risk lesions decreases
mortality, then patients who undergo NG lavage for their
upper GI bleeds should have lower mortality, right?!!

10. Conclusion
ER feel that it is both helpful to the gastroenterologist, and
more importantly, beneficial for the patient to place a NG tube
and perform a lavage.
The following should be reported to the
gastroenterologist when you call them:
 Was bloody material spontaneously returned upon
placement of the tube.
 What was the color of the material that was
lavaged, bright blood red, maroon, clear with
coffee-ground specks, etc.

11. Conclusion
 If you find evidence of bleeding, please lavage at
least 1-2 liters and tell us if the gastric contents
clear of the bloody contents.
 If there is no evidence of blood in the gastric
contents, please continue to lavage until you see
bilious material returned, so the gastroenterologist
can be sure that you are sampling contents beyond
the pylorus, a common site of peptic ulcers.

12. Can I simply avoid this procedure?
‫محروس‬ ‫خالد‬ ‫وليد‬Waleed Khalid Mahrous

13.  A negative NG lavage in an unstable patient with
suspected Upper GI bleed does not rule out a
bleed passed a closed pyloric sphincter, and a
positive NG lavage (that clears) in a stable patient
does not warrant more urgent EGD than an
unstable patient.
 It is common in my experience for GI docs to use
lack of NGT, or negative or equivocal lavages as a
way of delaying consultation till the
morning.

14. Incidentally, it is usually
the least experienced
member of the team
(medical student) who is
given the job of passing an
NGT without adequate
supervision.

15.  How good a diagnostic test is an NG tube?
Usefulness and Validity of Diagnostic Nasogastric
Aspiration in Patients Without Hematemesis.
 Ann Emerg Med 2004 gives us a sensitivity of 42%
and a specificity of 91%.
 A 42% sensitivity stinks. So if you are doing this test to
make sure that there is no upper GI bleeding, a negative
test would not rule this out.
 If you do get blood back then it is probably an upper GI
bleed.
 So the next obvious question is how does
this change management?

16.  One of the worst-tolerated procedures in Emergency
Medicine - placement of the NG tube.
 Unfortunately, when ER call GI fellow on-call for any
upper GI bleeding, the first question is invariably -
what did the NG lavage show?
‫محروس‬ ‫خالد‬ ‫وليد‬Waleed Khalid Mahrous

17.  Patients who underwent NGL were more likely to
have an endoscopy and to receive it sooner than
other patients.
 Lavage did not affect mortality, length of hospital
stay, or the need for transfusions or surgery. Bloody
aspirates were associated with high-risk lesions at
endoscopy.
 Conclude that NGL is associated with receiving early
endoscopy and might be useful in triage but does not
affect clinical outcomes.
‫محروس‬ ‫خالد‬ ‫وليد‬Waleed Khalid Mahrous

18.  The procedure increased the likelihood of early
endoscopy but not better patient outcomes, such as
lower mortality.
 Nasogastric tube insertion can be a traumatic
experience to the patient. May traumatize the
esophageal varices , mucosa and the gastric mucosa .
 The trauma marks can act as confounders to the
endoscopist

19. Comparison of patient and practitioner assessments of pain
from commonly performed emergency department procedures.
1. It is painful
What they did:
 Prospective, observational study
 1,171 procedures, from the 15 most common procedures
performed in the ED
 Patients recorded a pain score
What they found:
 The most painful procedure according to
patients was NG tube placement.
 NG tube placement was more painful than
intubation, abscess drainage, fracture reduction, and
urethral catheterization.
Ann Emerg Med. 1999 Jun;33(6):652-8.

20.  So, it has been rated the most painful
procedure we perform on a patient.
 There are many ways to lesson this pain like
local or systemic analgesia but it still stinks
for the patient.
 The gagging and spitting are not great for
the provider who is trying to keep the fragile
patient doctor bond intact.
Comparison of patient and practitioner assessments of pain
from commonly performed emergency department procedures.

21. Conclusion
 The most painful
procedure for ED
patients is NG tube
placement.
Ann Emerg Med. 1999 Jun;33(6):652-8.

22. Erythromycin infusion or gastric lavage for upper
gastrointestinal bleeding: a multicenter randomized controlled
trial.
2. NGL IS NOT the only way to get good
visualization during endoscopy
What they did:
 Prospective, randomized, multicenter study
 6 EDs, 253 patients with an upper GI bleed (UGIB)
 IV erythromycin (84 pts) vs NGT without erythromycin (85
pts) vs NGT with erythromycin (84 pts) for visualization
during endoscopy
What they found:
 No difference in visualization between groups
 No difference in duration of endoscopic procedure,
rebleeding, need for 2nd endoscopy, number of transfused
PRBCs, or mortality at 2, 7, and 30 days
Ann Emerg Med. 2011 Jun;57(6):582-9. doi: 10.1016/j.annemergmed.2011.01.001. Epub 2011 Feb 17.

23. Conclusion
 In acute UGIB, administration of IV erythromycin
provides satisfactory endoscopic visualization
without need for a NGL.
Ann Emerg Med. 2011 Jun;57(6):582-9. doi: 10.1016/j.annemergmed.2011.01.001. Epub 2011 Feb 17.

24. Impact of nasogastric lavage on outcomes in acute GI
bleeding
3. NGL DOES NOT improve mortality, length
of stay, or transfusion requirements
What they did:
 Retrospective analysis
 632 patients with GI bleeding to evaluate 30-day
mortality, mean hospital length of stay (LOS), and
transfusion requirements.
What they found:
 No statistical difference in 30 day mortality, mean
LOS, or transfusion requirements.
 NGL was associated with earlier time to
endoscopy.

25. Conclusion
 NGL is associated with earlier
performance of endoscopy, but NO
difference in clinical outcomes.

26.  The placement of a nasogastric tube should be considered
in select patients who have suspected active UGIB.
 The presence of bright red blood in a gastric aspirate can
be useful in identifying patients with high-risk
lesions, but is not as useful if coffee ground material or other
findings are present without red blood.
 It should be noted that the absence of blood in a gastric
aspirate does not exclude the presence of active UGIB,
because approximately 15% of patients with active bleeding
can have a negative result for nasogastric lavage.
 Because of these limitations, and the potential
patient discomfort, use of a nasogastric tube remains
controversial.
GASTROINTESTINAL ENDOSCOPY Volume 75, No. 6 : 2012

27. Nonvariceal upper gastrointestinal hemorrhage: ESGE Guideline 2015

28. NVUGIH – ESGE GL 2015
 In distinguishing upper from lower GI
bleeding, nasogastric aspiration has low
sensitivity 44% , high specificity 95% .
 In identifying severe UGIH, its sensitivity and
specificity are 77 % and 76%, respectively .
 Clinical signs and laboratory findings (e.g.,
hemodynamic shock and hemoglobin < 8 g/dL)
compared to nasogastric aspiration/lavage, had
similar ability to identify severe UGIH .
Nonvariceal upper gastrointestinal hemorrhage: ESGE Guideline 2015

29. NVUGIH – ESGE GL 2015
 Others have reported that nasogastric
aspiration/lavage failed to assist clinicians in
correctly predicting the need for endoscopic
hemostasis, did not improve visualization of
the stomach at endoscopy, or improve
clinically relevant outcomes such as
rebleeding, need for second-look endoscopy,
or blood transfusion requirements.
 It also should be noted that nasogastric
aspiration/lavage is a very uncomfortable
procedure that is not well tolerated or desired by
patients.
Nonvariceal upper gastrointestinal hemorrhage: ESGE Guideline 2015

32.  A3. Consider placement of a nasogastric
tube in selected patients because the
findings may have prognostic value.

33. Researchers argued here
 Placement of a nasogastric tube for
determining treatment of patients with upper
gastrointestinal bleeding may be unnecessary
since almost all these patients will eventually
undergo an endoscopic procedure.
 We found that the clinical judgment of the
clinician was just about as good as a nasogastric
tube examination - and didn't cause harm to
the patient," .

34.  "Since there is going to be an endoscopic follow-
up to confirm the diagnosis and perform
definitive treatment if necessary, there is no need to
continue to torture our patients with nasogastric tube
placement,”
 Placement of nasogastric tubes cause pain and epistaxis
in as many as 25% of patients undergoing the
procedure; in another 10% of patients, the tube
cannot be inserted due to some form of anatomic
problem.
 In the study ,pain, nasal bleeding, or nasogastric tube
failure occurred in 35% patients assigned to that
procedure.
Researchers argued here

35.  Many patients refused to undergo the
nasogastric tube placement." Those patients
who refused were also followed as to their
outcomes, and their clinical diagnosis
turned out to be similar to the others.
Researchers argued here

36. FINAL THOUGHTS
So what should we say to our gastroenterology
colleagues about NGL and UGIB?
 European Society of Gastrointestinal Endoscopy (ESGE)
Guideline 2015 guidelines, and
American College of Gastroenterology 2012 guidelines state NGL is
not recommended in patients with UGIB for diagnosis, prognosis,
visualization, or therapeutic effect .
 NG lavage DOES NOT help patients in the
emergency department with acute upper GI
bleed and is an outdated practice.
 It looks like there is no dilemma any longer.