Discussion:
Critical patients are at risk of multiple complications owing to both their illnesses and malnutrition. From having just a supportive role of maintaining lean body mass and immunity, the view on the role of nutrition has evolved into a more complicated one like minimizing metabolic response to inflammation and evading disease-related malnutrition 2, 4. As enteral feeding is more physiological and associated with less frequency of complications than parenteral feeding, in our center enteral feeding is preferred in cases with no contradiction.
Nasogastric and orogastric tubes are the most commonly inserted feeding tubes. In most cases, they are inserted blindly. Not only for feeding, but they are also used for gastric and intestinal decompression in intestinal obstructions, gastric lavage, and general anesthesia before emergency surgical procedures. We counseled the patient’s party regarding the alternative ways of enteral feeding like percutaneous endoscopic gastrostomy, given the risk of aspiration in long-term orogastric feeding. However, any surgical procedures were declined by the patient party who chose to continue on the orogastric tube feeding.
In most cases, enteral feeding via a nasogastric or orogastric tube is a safe procedure. Relative contraindications include conditions associated with trauma like skull base fracture and facial bone fractures. In these conditions, it is recommended to insert an orogastric tube under direct vision in place of an orogastric tube.5 There have been reported fatal incidents of insertion into the cranium itself in patients with basilar skull fracture6. Esophageal trauma or obstruction is another contraindication of orogastric tube insertion. It can worsen the injury, cause perforation or even get easily misplaced, especially in corrosive chemical ingestions.7
Other more commonly encountered problems include discomfort, obstruction of the tube, and trauma during insertion. Tube blockage occurs due to a variety of causes among which coagulation of feeding formula, tube kinking, medication fragments, and incompatible infusate precipitation are the common ones.8 Gently flushing the tube after each feed can help avoid the issue of feeding tube obstruction. In another incident of a rare complication, a tube was blocked owing to knotting in the stomach.9 It happened likely due to leaving an excess length of the tube in the stomach, emphasizing the need to avoid over inserting the tube. Long exposure to the harsh gastric acid is a cause for the tube to break. Forceful flushing of an obstructed tube can cause the distal end, usually a tip to break.10 In our case though, the tube was fractured in the middle and there was no issue in the earlier feed. The tube was flushed regularly after feeding and no resistance was encountered in doing so. It is not likely that acid or forceful flushing is the cause of the tube fracture in our patient.
When a tube is fractured, it migrates distally owing to the peristalsis in the gut tube. It is essentially managed as an ingested foreign body. A study of endoscopic evaluation of foreign bodies shows that objects longer than 6 cm are at risk of not passing the pylorus even after 48 hours after ingestion.11. Smaller pieces like the tip of a feeding tube may be followed by a serial radiographic evaluation to allow them to pass through the alimentary canal, but for larger foreign bodies like in our case, it is not a wise idea to just follow the passage tube as it carries the risk of intestinal obstruction and an upper gastrointestinal endoscopy is the standard practice for the removal of any ingested foreign body.12
Our patient had poor swallowing owing to the stroke and we relied on our clinical judgment to do a laryngoscopic examination for the possibility of the tube being in the throat. And luckily, the tube was still in the esophagus with a proximal end in the laryngopharynx. It was retrieved without difficulty in the same setting. Another reason for the tube still being in an accessible position could have been the identification of the fractured tube before it could migrate to the stomach.