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Esophageal perforation by nasoenteral feeding tube—A case report
CLINICAL
SHORT
NUTRITION (1988) 7: I u-21) c Lonpman Group 1:h: I.ld ,99x
PAPER
Esophageal Perforation by Nasoenteral Feeding Tube-A Case Report C. B. Queralt-Solar-i *, S. Celaya-Ptkezt *‘l‘m~xFieta 30,50007-Zaragoza, Spain.
and R. Lozano-Mantecht
+Intensive Care Uit, Department of Surgery, Lozano-Bless University Hospital, Zaragoza, Spain. Reprinr requests to C.B.Q.)
The use of nasoenteral feeding tubes has increased in recent years. However, the rigid .4BSTRACT To prevent the perforation of wire used to stiffen the tube during insertion can produce complications. the enteral or respiratory tract, the wire introducer should not be advanced beyond the nasopharynx, and the placement of the tube should be systematically verified with X-rays.
INTRODUCTION The use of nasoenteral feeding tubes is a good alternative to central venous hyperalimentation in the nutripatient with tionally compromised intact gastrointestinal function because the enteral technique is safer and more physiological than the intravenous approach [l]. Although such tubes are easily handled and carry minimal morbidity, their increasing use causes some traumatic complications. We present a case of esophageal perforation by nasoenteral feeding tube use, in order to point out the particular hazard of this complication in neurologically compromised patients. Fig. 1 Chest X-ray showing the position of the catheter tip (arrowed). CASE
REPORT pleural content was drained by insertion of an intercostal tube for continuous closed drainage and central venous hyperalimentation was started. The thoracic tube was removed on the 17th day, and the patient observed with no sign of deterioration.
A ho-year-old male patient was admitted for craniocerebral injury (level 7 of Glasgow’s scale). CT-scan showed two areas of contusion and cerebral edema (left parietal lobe and right frontal lobe). The patient was treated with 72 h barbiturate-induced coma (pentobarbital!. Corticsteroids were not used since the patient had a history of bleeding duodenal ulcer. He also required nasoenteral intubation, oxygen, antibiotics, cimetidine and parenteral fluids. On the 7th hospital day, a nasoenteral feeding tube was placed, but on the 12th day, the tube was accidentally removed. Another soft small-diameter tube was introduced through nasopharynx. The patient expericnccd immediate respiratory distress. An X-ray examination showed a collection of fluid in the pleural space around the entire right lung, caused by misplacement of the tube (the mercury filled end was in the costophrenic showed two persinus, kFig. 1). Fibroesophagoscopy forations of the thoracic esophagus. Immediately the ”
DISCUSSION Nasoenteral feeding tubes are used for nutritional support in a wide variety of patients [ 11. Despite the nature of the siliconed tube with its small caliber and soft pliable construction, it can be hazardous because a rigid wire is required as an aid in the passage through the nasopharynx. This wire can perforate structures in the nasoenteral tract if the tube is misdirected. Thus several complications have been reported in the literature: 1) Esophaeal 19
or gastric perforation
[2-41.
20
ESOPHAGEAL
PERFORATION
BY NASOENTERAL
FEEDING
2) Endotracheal
placement with bronchial perforation with or without respiratory descompensation), [510]. 3) Pharingeal dissection [ 111. 4) Intranasal retraction [ 121. 5) Penetration in the brain [ 131. Fortunately, when the tube is misplaced in the pleural cavity, as in our case, usually it only causes sterile pleuritis which should resolve with appropiate early drainage. If the treatment is correct and rapid the risk of infection is very low because the majority of feeding solutions are sterile and only mildly irritant. In order to minimise the above mentioned complications, we can take several measures: 1) We must be aware of the possibility of complication with such nasoenteral tubes. 2) To identify the patient with increased risk. 3) Cautious placement by experienced staff. 4) Use of the wire introducer only for passage of the nasopharynx. 5) Fluoroscopic control or X-ray verification of catheter location. We agree with other authors [6,7,9, 10, 14, 151, that the last point is the most important measure.
REFERENCES [l] Hemysfield S B, Bethel R A, Ansley J D et al 1979 Enteral hyperalimentation: an alternative to central venous hyperalimentation. Annals of Internal Medicine 90: 63-7 1 [2] Meyers MA, Ghahremani G G 1981 Iatrogenic Gastrointestinal Complications. Springer-Verlag, pp 66-72 Submission dare: 10 February
TUBE-A
CASE REPORT
[31 James R H 1978 An unusual
complication of passing a narrow bore nasogastric tube. Anaesthesia 33: 716-718 G G, Turner M A, Port R B 1980 [41 Ghahremani Iatrogenic intubation injuries of the upper gastrointestinal tract in adults. Gastrointestinal Radiology 5: l-7 151 Baloch J G, Adler S J, Van Der Woude J et al 1983 Pneumothorax as a complication of feeding tube placement. American Journal of Roentgenology 141: 1275-1277 [61 Olbrantz K R, Gelfand D, Choplin R et al 1985 Pneumothorax complicating enteral feeding tube placement. Journal of parenteral and enteral nutrition 9:210-211 171 Nakao M A, Killam D, Wilson R 1983 Pneumothorax secondary to inadvertent nasotracheal tube. Critical Care Medicine 11: 2 1O-2 11 PI Johnstone R E, Lie P L 1972 Complication of intubation of gastrointestinal tract. Journal of the American Medical Association 221: 192-199 (5 R, Battaglini J W 1984 An unusual [91 Schorlermmer complication of nasoenteral feeding with small-diameter feeding tubes. Annals of Surgery 199: 104-106 intubation [lOI Dorsey J S, Cogordan J 1985 Nasotracheal and pulmonary parenchymal perforation. Chest 87: 131-132 [Ill Siemers P T, Reinke R T 1976 Perforation of the nasopharynx by nasogastric intubation: a rare cause of left pleural affusion and pneumomediatinum. American Journal of Roentgenology 127: 341-343 [I21 Bohnker B K, Artman L E, Hoskins W J 1985 Intranasal retraction of nasogastric feeding tube: Case report and suggestion for design modification. Journal of parenteral and enteral nutrition 9: 53-54 iI31 Bouzarth W F 1978 Intracranial nasogastric tube insertion. Journal of Trauma 18: 818-820 K G, Bowman M A 1981 Fatal hydrothorax P41 Torrington and empyema complicating a malpositioned nasogastric tube. Chest 79: 240-242 iI51 Harvey P B, Bull P T, Harris D L 1981 Accidental intrapulmonary clinifeed. Anaesthesia 36: 518-521
1986. Accepted after revision: 12 April 1987
SHORT
NUTRITION (1988) 7: I u-21) c Lonpman Group 1:h: I.ld ,99x
PAPER
Esophageal Perforation by Nasoenteral Feeding Tube-A Case Report C. B. Queralt-Solar-i *, S. Celaya-Ptkezt *‘l‘m~xFieta 30,50007-Zaragoza, Spain.
and R. Lozano-Mantecht
+Intensive Care Uit, Department of Surgery, Lozano-Bless University Hospital, Zaragoza, Spain. Reprinr requests to C.B.Q.)
The use of nasoenteral feeding tubes has increased in recent years. However, the rigid .4BSTRACT To prevent the perforation of wire used to stiffen the tube during insertion can produce complications. the enteral or respiratory tract, the wire introducer should not be advanced beyond the nasopharynx, and the placement of the tube should be systematically verified with X-rays.
INTRODUCTION The use of nasoenteral feeding tubes is a good alternative to central venous hyperalimentation in the nutripatient with tionally compromised intact gastrointestinal function because the enteral technique is safer and more physiological than the intravenous approach [l]. Although such tubes are easily handled and carry minimal morbidity, their increasing use causes some traumatic complications. We present a case of esophageal perforation by nasoenteral feeding tube use, in order to point out the particular hazard of this complication in neurologically compromised patients. Fig. 1 Chest X-ray showing the position of the catheter tip (arrowed). CASE
REPORT pleural content was drained by insertion of an intercostal tube for continuous closed drainage and central venous hyperalimentation was started. The thoracic tube was removed on the 17th day, and the patient observed with no sign of deterioration.
A ho-year-old male patient was admitted for craniocerebral injury (level 7 of Glasgow’s scale). CT-scan showed two areas of contusion and cerebral edema (left parietal lobe and right frontal lobe). The patient was treated with 72 h barbiturate-induced coma (pentobarbital!. Corticsteroids were not used since the patient had a history of bleeding duodenal ulcer. He also required nasoenteral intubation, oxygen, antibiotics, cimetidine and parenteral fluids. On the 7th hospital day, a nasoenteral feeding tube was placed, but on the 12th day, the tube was accidentally removed. Another soft small-diameter tube was introduced through nasopharynx. The patient expericnccd immediate respiratory distress. An X-ray examination showed a collection of fluid in the pleural space around the entire right lung, caused by misplacement of the tube (the mercury filled end was in the costophrenic showed two persinus, kFig. 1). Fibroesophagoscopy forations of the thoracic esophagus. Immediately the ”
DISCUSSION Nasoenteral feeding tubes are used for nutritional support in a wide variety of patients [ 11. Despite the nature of the siliconed tube with its small caliber and soft pliable construction, it can be hazardous because a rigid wire is required as an aid in the passage through the nasopharynx. This wire can perforate structures in the nasoenteral tract if the tube is misdirected. Thus several complications have been reported in the literature: 1) Esophaeal 19
or gastric perforation
[2-41.
20
ESOPHAGEAL
PERFORATION
BY NASOENTERAL
FEEDING
2) Endotracheal
placement with bronchial perforation with or without respiratory descompensation), [510]. 3) Pharingeal dissection [ 111. 4) Intranasal retraction [ 121. 5) Penetration in the brain [ 131. Fortunately, when the tube is misplaced in the pleural cavity, as in our case, usually it only causes sterile pleuritis which should resolve with appropiate early drainage. If the treatment is correct and rapid the risk of infection is very low because the majority of feeding solutions are sterile and only mildly irritant. In order to minimise the above mentioned complications, we can take several measures: 1) We must be aware of the possibility of complication with such nasoenteral tubes. 2) To identify the patient with increased risk. 3) Cautious placement by experienced staff. 4) Use of the wire introducer only for passage of the nasopharynx. 5) Fluoroscopic control or X-ray verification of catheter location. We agree with other authors [6,7,9, 10, 14, 151, that the last point is the most important measure.
REFERENCES [l] Hemysfield S B, Bethel R A, Ansley J D et al 1979 Enteral hyperalimentation: an alternative to central venous hyperalimentation. Annals of Internal Medicine 90: 63-7 1 [2] Meyers MA, Ghahremani G G 1981 Iatrogenic Gastrointestinal Complications. Springer-Verlag, pp 66-72 Submission dare: 10 February
TUBE-A
CASE REPORT
[31 James R H 1978 An unusual
complication of passing a narrow bore nasogastric tube. Anaesthesia 33: 716-718 G G, Turner M A, Port R B 1980 [41 Ghahremani Iatrogenic intubation injuries of the upper gastrointestinal tract in adults. Gastrointestinal Radiology 5: l-7 151 Baloch J G, Adler S J, Van Der Woude J et al 1983 Pneumothorax as a complication of feeding tube placement. American Journal of Roentgenology 141: 1275-1277 [61 Olbrantz K R, Gelfand D, Choplin R et al 1985 Pneumothorax complicating enteral feeding tube placement. Journal of parenteral and enteral nutrition 9:210-211 171 Nakao M A, Killam D, Wilson R 1983 Pneumothorax secondary to inadvertent nasotracheal tube. Critical Care Medicine 11: 2 1O-2 11 PI Johnstone R E, Lie P L 1972 Complication of intubation of gastrointestinal tract. Journal of the American Medical Association 221: 192-199 (5 R, Battaglini J W 1984 An unusual [91 Schorlermmer complication of nasoenteral feeding with small-diameter feeding tubes. Annals of Surgery 199: 104-106 intubation [lOI Dorsey J S, Cogordan J 1985 Nasotracheal and pulmonary parenchymal perforation. Chest 87: 131-132 [Ill Siemers P T, Reinke R T 1976 Perforation of the nasopharynx by nasogastric intubation: a rare cause of left pleural affusion and pneumomediatinum. American Journal of Roentgenology 127: 341-343 [I21 Bohnker B K, Artman L E, Hoskins W J 1985 Intranasal retraction of nasogastric feeding tube: Case report and suggestion for design modification. Journal of parenteral and enteral nutrition 9: 53-54 iI31 Bouzarth W F 1978 Intracranial nasogastric tube insertion. Journal of Trauma 18: 818-820 K G, Bowman M A 1981 Fatal hydrothorax P41 Torrington and empyema complicating a malpositioned nasogastric tube. Chest 79: 240-242 iI51 Harvey P B, Bull P T, Harris D L 1981 Accidental intrapulmonary clinifeed. Anaesthesia 36: 518-521
1986. Accepted after revision: 12 April 1987