Cappell Mitchell S
Gastroenterology Fellowship Training Program, Division of Gastroenterology, Department of Medicine, Albert Einstein Medical Center, Klein Professional Building, Suite 363, 5401 Old York Road, Philadelphia, Pennsylvania 19141, USA.
Dig Dis Sci. 2005 Nov;50(11):2063-70. doi: 10.1007/s10620-005-3008-8.
Our purpose was to analyze risks versus benefits of nasogastric (NG) intubation for gastrointestinal (GI) bleeding performed soon after myocardial infarction (MI). While NG intubation and aspiration is relatively safe, clinically beneficial, and routinely performed in the general population for recent GI bleeding, its safety after MI is unstudied and unknown. In addition to the usual complications of NG tubes, patients status post-MI may be particularly susceptible to myocardial ischemia or cardiac arrhythmias from anxiety or discomfort during intubation. We studied NG intubation within 30 days of MI in 125 patients at two hospitals from 1986 through 2001. Indications for NG intubation included melena in 55 patients; fecal occult blood with an acute hematocrit decline, severe anemia, or sudden hypotension in 37; hematemesis in 18; bright red blood per rectum in 8; and dark red blood per rectum in 7. The intubation was performed on average 5.3 +/- 7.2 (SD) days after MI. NG aspiration revealed bright red blood in 38 patients, "coffee grounds"-appearing blood in 45, and clear (or bilious) fluid in 42. Among 114 of the patients undergoing esophagogastroduodenoscopy (EGD), EGD revealed the cause of bleeding in 79 (95%) of 83 patients with a grossly bloody NG aspirate versus 12 (39%) of 31 patients with a clear aspirate (P < 0.0001, OR = 31.3, OR CI = 9.4-103.1). Among 85 patients undergoing EGD within 16 hr of NG intubation, stigmata of recent hemorrhage were present in 28 (42%) of 66 with a bloody NG aspirate versus 3 (16%) of 19 with a clear aspirate (P = 0.06, OR = 3.93). Among 35 patients undergoing lower GI endoscopy, lower endoscopy revealed the cause of bleeding in 14 (56%) of 25 patients with a clear NG aspirate versus 1 (10%) of 10 patients with a grossly bloody aspirate (P < 0.04, OR = 11.46, OR CI = 1.55-78.3). The two NG tube complications (epistaxis during intubation and gastric erosions from NG suctioning) were neither cardiac nor major (requiring blood transfusions). This study suggests that short-term NG intubation is relatively safe and may be beneficial and indicated for acute GI bleeding after recent MI. Aside from improving visualization at EGD, the potential benefits include providing a rational basis for the timing of endoscopy (urgent versus semielective), for prioritizing the order of endoscopy (EGD versus colonoscopy), and for avoiding or deferring endoscopy in low-yield situations (e.g., colonoscopy when the NG aspirate is bloody). These benefits may be particularly relevant in patients after recent MI due to their increased endoscopic risks.
我们的目的是分析心肌梗死（MI）后不久进行的用于胃肠道（GI）出血的鼻胃管（NG）插管的风险与益处。虽然NG插管和抽吸相对安全、具有临床益处，且在普通人群中对于近期GI出血是常规操作，但MI后其安全性尚未得到研究且未知。除了NG管常见的并发症外，MI后的患者在插管过程中可能因焦虑或不适而特别容易发生心肌缺血或心律失常。我们研究了1986年至2001年期间两家医院125例MI后30天内进行的NG插管情况。NG插管的指征包括55例患者出现黑便；37例患者粪便潜血伴急性血细胞比容下降、严重贫血或突然低血压；18例患者呕血；8例患者直肠排出鲜红色血液；7例患者直肠排出暗红色血液。插管平均在MI后5.3±7.2（标准差）天进行。NG抽吸显示38例患者为鲜红色血液，45例患者为“咖啡渣样”血液，42例患者为清亮（或胆汁样）液体。在接受食管胃十二指肠镜检查（EGD）的114例患者中，对于83例NG抽吸物明显带血的患者，EGD发现79例（95%）出血原因，而对于31例抽吸物清亮的患者，EGD发现12例（39%）出血原因（P<0.0001，比值比[OR]=31.3，OR可信区间[CI]=9.4 - 103.1）。在NG插管后16小时内接受EGD的85例患者中，66例NG抽吸物带血的患者中有28例（42%）存在近期出血的迹象，而19例抽吸物清亮的患者中有3例（16%）存在近期出血的迹象（P = 0.06，OR = 3.93）。在接受下消化道内镜检查的35例患者中，对于25例NG抽吸物清亮的患者，下消化道内镜检查发现14例（56%）出血原因，而对于10例NG抽吸物明显带血的患者，下消化道内镜检查发现1例（10%）出血原因（P<0.04，OR = 11.46，OR CI = 1.55 - 78.3）。两种NG管并发症（插管时鼻出血和NG抽吸导致的胃糜烂）既非心脏相关并发症也非严重并发症（无需输血）。本研究表明，短期NG插管相对安全，可能有益且适用于近期MI后的急性GI出血。除了改善EGD的视野外，潜在益处包括为内镜检查的时机（紧急与半择期）、确定内镜检查的优先顺序（EGD与结肠镜检查）以及在低收益情况下（如NG抽吸物带血时进行结肠镜检查）避免或推迟内镜检查提供合理依据。由于近期MI患者的内镜检查风险增加，这些益处可能尤为重要。
