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      Occult Perforation of the Esophagus during Removal of an Enteral Feeding Tube: A Case Report and Literature Review


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          Background. The use of oral or nasal route for enteral feeding is a standard practice in intensive care patients with a safe profile in general. However, complications associated with the insertion of a nasogastric (NGT) or orogastric tube (OGT) are common in the medical literature compared to the removal of such tubes. Case presentation. We presented a 38-year-old male who was involved in a motor-vehicle collision and found with low Glasgow Coma Scale outside his vehicle. He had polytrauma and was intubated—and commenced on enteral feeding via an OGT. Esophageal bezoar developed within a few days around the feeding tube, resulting in significant force being required to remove it, which was complicated by esophageal perforation. The esophageal injury was treated conservatively with uneventful recovery. Discussion and conclusions. Although limited case reports of esophageal enteral feeding bezoar formation do exist in the literature, we believe that this is the first case report of esophageal perforation due to the forceful removal of a wedged OGT secondary to esophageal bezoar formation. Morbidity associated with OGT/NGT is not common and may require a high index of suspicion to be identified. This is especially true if resistance is appreciated while removing the NGT/OGT. Gastroenterology consultation is recommended as early as possible to detect and manage any complications, however, their role was very limited in such stable case. In addition, early computed tomography (CT) can be considered for timely recognition of esophageal perforation. Non-operative management may be considered in stable patients, especially if the leak is in the cervical portion of the esophagus. Finally, prevention is better than cure, so being diligent in confirming NGT/OGT position, both radiologically and by measuring the tube length at the nostril/mouth, is the key to avoid misplacement and complication. This case raises the awareness of physician for such preventable iatrogenic event.

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          Most cited references11

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          Bezoars: classification, pathophysiology, and treatment.

          Bezoars, accumulations of foreign material in the stomach, have been known to occur in animals and man for centuries. The incidence of bezoars in human patients has increased as a result of operative manipulation of the gastrointestinal tract. Composed of vegetable matter, hair, or more unusual materials like shellac or cement, they may lead to anorexia, weight loss, bleeding, obstruction, or perforation of the alimentary tract. Although this entity is often recognized radiologically, endoscopy provides the most accurate means for identification and classification. Many bezoars can be removed endoscopically, but some will require operative intervention. Once removed, emphasis must be placed upon prevention of recurrence. Physicians must learn to recognize and classify bezoars correctly in order to provide the most appropriate therapy in each instance.
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            Implementation of the evidence review on best practice for confirming the correct placement of nasogastric tube in patients in an acute care hospital.

            Nasogastric (NG) tube is a device passed through the gastrointestinal tract of patients for the purpose of feeding, gastric decompression and medication administration. However, a small risk involved in the process is that the tube may be misplaced into the trachea during insertion or may get displaced at a later stage, leading to disastrous results. Recent adverse incidences arising out of the misplacement of NG tube raised concerns among the nursing and medical community and the Patient Safety Officer of the hospital. The Evidence Based Nursing Unit, in collaboration with some of the key nursing leaders in nursing administration, was tasked to explore and institute the current best practice in confirming the correct placement of NG tube. The aim of this project was to institute the best practice to confirm the correct placement of NG tube in patients in an acute care hospital setting. The project comprised of a few stages. The first stage involved reviewing the existing recommendations and guidelines on the methods for checking correct NG tube placement. The second stage involved incorporation of the change of practice into the clinical setting. The final stage was to monitor and evaluate the impact of the new practice on the patients, nurses and other healthcare professionals. Evidence search from guidelines and journals supported the test that used pH indicator instead of the litmus test. There is no evidence that supports the method of auscultation and bubbling to confirm correct NG tube placement in the absence of aspirate. Radiology remains the 'gold standard' for checking correct NG tube placement. The revised method of NG tube placement and workflow was incorporated in the revised Standard Operating Procedures. A total of 17 roadshows were conducted to create awareness regarding the new method amongst the nurses, and the implementation of the revised method and workflow was commenced on 3 November 2008. The initial audit conducted 1 month after the practice change was implemented reported 26 (50%) observations of NG tube feeding in 26 audit wards. The key areas of practice change in feeding when tube placement was confirmed (84.6%) and proper testing of aspirate (76.9%) showed good compliance. The implementation of the change in the practice of confirming the correct placement of the NG tube in patients requires good coordination and a multidisciplinary team approach. © 2011 The Authors. International Journal of Evidence-Based Healthcare © 2011 The Joanna Briggs Institute.
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              Esophageal bezoar formation due to solidification of enteral feed administered through a malpositioned nasogastric tube: case report and review of the literature.

              Enteral feeding is now standard and routine practice in intensive care. The use of a nasogastric tube for enteral feeding is generally considered to be safe, but tubes with small bores can sometimes lead to aspiration or passage clogging when malpositioned in sedated patients who are on long-term mechanical ventilation. Thus, accurate confirmation of correct placement is mandatory in such patients. This is not always the case, but this faulty practice can lead to serious complications in the absence of potential bezoar-forming medicines or gastrointestinal pathology. We present here one such interesting case of a patient who developed esophageal bezoar due to a malpositioned nasogastric tube for administering a casein-containing feed. In addition, we present a review of the literature.

                Author and article information

                Case Rep Surg
                Case Rep Surg
                Case Reports in Surgery
                29 March 2023
                : 2023
                : 4230158
                1Department of Surgery, Trauma Surgery, Hamad Medical Corporation, Doha, Qatar
                2Department of Surgery, Universidad Nacional Pedro Henriquez Urena, Santo Domingo, Dominican Republic
                3Department of Clinical Medicine, Weill Cornell Medical College, Doha, Qatar
                Author notes

                Academic Editor: Paola De Nardi

                Author information
                Copyright © 2023 Mohammad Alabdallat et al.

                This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

                : 23 July 2022
                : 3 March 2023
                : 9 March 2023
                Case Report



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