Introduction
In general, enteral feeding is used when oral feeding is not possible due to dysphagia in patients with brain damage, such as stroke or traumatic brain hemorrhage. The most commonly used route of enteral feeding is the nasogastric tube(NGT), which is easy to insert and inexpensive. In principle, the length of the NGT should be determined by adding the length from the tip of the nose to the earlobe to the length from the earlobe to the xiphisternum. In practice, however, the length is generally determined based on the gender and height of the patient. In this patient case, asymptomatic perforation occurred due to the NGT insertion, and we could see the importance of proper adjustment of the length of the NGT when feeding the patient.
Case presentation
On February 6, 2020, an 80-year-old male patient with no specific medical history other than A.fib, old MI, and pituitary tumor was admitted to the Department of Physical Medicine & Rehabilitation for examination and treatment of dysphagia. No recent stroke was found other than traces of old CVA on the brain image test performed after hospitalization. Since 2018, the patient has had a mouth salivation symptom, but there was no problem with the oral feeding. However, from December 31, 2019, the general condition of this patient worsened after receiving ICU treatment with pneumonia, and his dysphagia symptom also became severer. VFSS was performed on February 4, 2020, and the results was penetration (+), aspiration (-), remnant 90% in semisolid 4/8cc and 50% in multiple swallowing, and during swallow aspiration (+) in liquid 4cc, so NGT was inserted. In EGD and manometry, no specific signs that can cause dysphagia were observed. On the APCT that was performed on Feb. 21 to evaluate the possibility of dysphagia caused by cancer, the sign of perforation of the gastric fundus by penetration of the stomach wall by NGT was observed. No foreign substances were found other than free air in the diaphragm area, and the level of inflammation was normal with no evidence of peritonitis. At that time, the patient was in NPO state for enhanced CT scanning, and right after detection of the perforation, the NGT was removed and broad-spectrum antibiotic was used and NPO and TPN were performed for 2 weeks under the cooperative treatment with GS and GI. After checking the wound healing on f/u EGD and f/u APCT, PEG tube insertion was conducted on March 10, 2020.
Conclusion
This patient was a dysphagia patient, and no clinical symptoms such as abdominal pain, tenderness, and rigidity were found after insertion of the NGT for enteral feeding, but gastric perforation was observed on APCT that was performed accidentally. If feeding continued without performing the APCT test, it could lead to a dangerous situation such as peritonitis. Based on these results, it is necessary to think about the necessity of adjusting the length of the NGT considering characteristics of patients and regular X-ray after insertion. |
