Nasogastric tubes for small bowel obstruction: more pain than evidence - First10EM (2023)

In my opinion, the use of NG tubes for intestinal obstruction is an anachronism. I grew up hearing literature that said that NG tubes are not beneficial, but that they routinely rank as one of the most painful things we do to our patients. In my opinion, this was a classic example of a medical myth that had been consigned to medical history, along with things like leeches and trephination. However, every time I admit a patient with a bowel obstruction, the topic of NG tubes comes up, so I think we need a quick blog post.

Like many historical medical practices, NG was adopted long before the era of evidence-based medicine. Its use was based on common sense and some pathophysiology, but not evidence. Unfortunately, common sense and the physiology of medicine have always led us astray.

There is no evidence that NG tubes help.

The use of nasogastric tubes to decompress the stomach in small bowel obstruction appears to have originated with Dr. Owen Wangensteen. Over the course of a few decades of intestinal obstruction research, the mortality rate at Massachusetts General Hospital dropped from about 45% in the 1920s to about 20% in the late 1930s. For decades , this decrease in mortality, reported through case series , was the evidence that promoted the widespread use of NG tubes. (Edlich 1996) Obviously, by modern standards, a series of cases in which many changes were dated over many decades, from a time when CT was not available and mortality was dramatically higher, does not count as a very high standard of evidence. high. At best, this is hypothesis generation.

Unfortunately, to the best of my knowledge, this hypothesis has never really been tested. There is not a single randomized trial of any size or quality that addresses this issue. All we have are observational data (and the modern-era observational data seems to conflict with Wangensteen's case series).

There are some important limitations to the observational data, because patients who receive NG tubes are likely to be different from those who are treated without them, but the available observational data do not support a benefit from the use of NG tubes. In a chart review of 290 patients admitted with small bowel obstructions, approximately 20% were treated without an NG tube. The use of the NG tube was associated with worse results in all aspects: longer resolution time, longer hospital stay, and higher rate of complications. Conservative management was successful in 2/3 of the patients and was the same regardless of whether or not an NG was placed. Of note, almost 2/3 of the patients who had a nasogastric tube placed had minimal drainage, indicating that the procedure was unable to help the majority of patients. (Fonseca 2013)

The Best Evidence Topic Reports (Best BET) series covered this topic in 2014, and the only relevant article they identified was Fonseca's 2013 observational study. The bottom line: “There is no scientific evidence for the routine use of nasogastric tubes in adults with occlusion of the small intestine. (Paradise 2014)

Another retrospective chart review included 181 patients with small bowel obstruction, half of whom were treated with nasogastric decompression. There was no association between the use of the NG tube and death, surgery, or bowel resection. NG tube decompression was associated with a longer hospital stay (median 5 vs 3 days, p<0.0001). There were significant baseline differences between groups: nasogastric tubes were used more frequently in elderly patients and in those with malignancy, again severely limiting the value of observational data. (Bermann 2017)

(Video) Sondino si sondino no nell'occlusione intestinale

Although somewhat tangential, prophylactic nasogastric tubes have long been used to promote early return of normal bowel function in the setting of ileus after surgery. However, a systematic review of 28 studies including 4000 patients found the exact opposite (ileus resolved more rapidly in patients without NG tube) and concluded that "routine nasogastric decompression does not achieve any of the intended goals and therefore therefore, it should be abandoned in favor of selective therapy via nasogastric tube” (Nelson 2005).

Long story short: We have no idea if NG tubes help. There is simply no quality evidence. Observational data suggest harm from longer hospital stays, longer time to resolution, and more complications, but the data are so weak that they cannot be trusted. We just don't know. Some patients may benefit, but observational data suggest that nasogastric tubes should not be used routinely.

On the other hand, NG tubes clearly cause damage

NG tubes are very painful. They are routinely ranked as one of the worst things we do to patients.

In a classic survey of admitted adult patients undergoing various medical procedures, the NG tube was ranked at the top of the list, with an average pain score of 8.8 on a 10-point scale, placing it ahead of all others. mechanical ventilation (8.0). , placement of central lines (6.5), arterial lines (3.4) and Foley catheters (6.2). (Morrison 1998) Although the study numbers are imperfect and there are several potential biases, when patients tell us they are in pain, we must listen. Numerous other studies have confirmed that this is a very painful procedure. (for example, Singer 1999; Cullen 2004)

It is possible to limit the pain associated with NG placement using topical lidocaine, although it is not clear how long the analgesic effect will persist as these tubes are generally left in place for many days. (Kuo 2010) Nasal pain is not the only problem with NG tubes. Patients rate the discomfort of choking at least as high as the nasal pain of insertion. (Singer 1999) Also, pain is not completely eliminated, which means that the harm will still outweigh the benefit if there is no benefit at all.

98% of ER physicians believe NG tube insertion is painful, but only 28% believe the pain relief options they provide are effective, and more than half are dissatisfied with their current practice. (Juhl 2005) This probably explains why ER physicians have been quicker to change their practice around this medical myth than many others where we do not immediately see the harm of our actions (such asstress testoPPI in digestive bleeding).

Use of GN in other conditions

Historically, NGs have been used for many other conditions in emergency medicine, from evaluation of upper GI bleeding to administration of activated charcoal. I won't do an in-depth review of the evidence for these other "indications," largely because there really isn't any evidence.

I think we all know that the NG tube is not accurate in diagnosing upper GI bleeding. I will occasionally use an NG tube as an active bleeding monitor in critically ill patients, but the evidence suggests that routine NG tubes in upper GI bleeds are useless. (Huang 2011; Palamidessi 2010)

I have never heard that the NG tube could be helpful in pancreatitis, but this is apparently a widely held belief in some parts of the world. Once again, the evidence seems to suggest the opposite, with faster recovery in patients randomized to no NG tube. (Sar 1986)

NG is sometimes a useful route for drug delivery and even hydration, but the risks need to be weighed against the benefits. It has often been used for drugs that have no proven benefit (such as charcoal), which only compounds the lack of benefit of the NG tube itself. However, I am happy to place an NG tube if it is the only way to deliver a potentially life-saving medication, such as administering aspirin to an unconscious STEMI patient. (Of course, the damage from NG tubes is also negligible in unconscious patients.)

NG has been suggested as a possible alternative to IV for rehydration in pediatrics, but considering that the pain of an NG tube is considered much greater than the pain of an IV, it seems that NG would be the worst alternative in the vast majority. of the cases. cases cases

Most of the time, I think the role of the NG tube isincrediblylimited in emergency medicine. We have to recognize its significant damage, being one of the most painful procedures we perform on patients. Given this, there is a high burden of proof for those who suggest the practice. We need to see evidence of benefit before putting our patients through this procedure.


This is clearly a harmful procedure. Patients find this more painful than almost anything else we do in medicine. This harm means that we must have evidence of benefit before we can consider this practice ethical. At this point there is no evidence and therefore NG probesit absolutely should not be routinely placed in patients with small bowel obstructions.

This conclusion does not mean that NG tubes offer no benefit. Evidence on the subject is essentially non-existent. We just don't know. But we know that the tubes cause harm, so the burden of proof is on whoever wants to subject patients to that harm. Before using NG tubes, we must demonstrate that there is a benefit that outweighs the known harm. If nasogastric tubes are as important as surgeons seem to think (if there is a large absolute benefit), then it should be fairly easy to demonstrate that benefit in an RCT. However, until we see this RCT, it is unfair to patients to undergo this unproven painful procedure.


Monthly EP: I Declare the End of the NG Reflective Tube

EP Monthly: The NG probe for gastrointestinal bleeding: cruel and unusual punishment

Monthly PE: NG tube pain preventable but not preventable


[ PMC free article ] [ PubMed ] Berman DJ, Ijaz H, Alkhunaizi M, Kulie PE, Vaziri K, Richards LM, Meltzer AC. Nasogastric decompression not associated with reduction surgery or intestinal ischemia due to acute small bowel obstruction. J Emerg Med. 2017 December; 35(12): 1919–1921. doi: 10.1016/j.ajem.2017.08.029. Epub 2017 15 August. IDPM:28912083

Cullen L, Taylor D, Taylor S, Chu K. Nebulized lidocaine decreases the discomfort of nasogastric tube insertion: a randomized, double-blind trial. Ann Emerg Med. 2004 Aug; 44(2): 131-7. doi: 10.1016/j.annemerged.2004.03.033. PMID:15278085

Edlich RF, Woods JA. Wangensteen's transformation of the treatment of intestinal obstruction from an empirical art to a scientific discipline. J Emerg Med. 1997 Mar-April;15(2):235-41. doi: 10.1016/s0736-4679(96)00351-4. PMID:9144067

Fonseca AL, Schuster KM, Maung AA, Kaplan LJ, Davis KA. Routine nasogastric decompression in small bowel obstruction: is it really necessary? I am Surgery. April 2013; 79(4): 422-8. PMID:23574854

Huang ES, Karsan S, Kanwal F, Singh I, Makhani M, Spiegel BM. Impact of nasogastric lavage on the outcomes of acute GI bleeding. Endosc. gastrointestinal. 2011 November; 74(5):971-80. doi: 10.1016/j.gie.2011.04.045. Epub Jul 7, 2011. IDPM:21737077

Juhl GA, Conners GP. Practices and attitudes of emergency physicians regarding the anesthetic procedure for nasogastric tube insertion. Emerg Med J. 2005 April; 22(4):243-5. doi: 10.1136/emj.2004.015602. PMID:15788820

Kuo YW, Yen M, Fetzer S, Lee JD. Pain reduction of nasogastric intubation with nebulized and atomized lidocaine: a systematic review and meta-analysis. J Treatment of pain symptoms. 2010 October; 40(4): 613-20. doi: 10.1016/j.jpainsymman.2010.01.025. Epub Aug 3, 2010. PMID:20678892

Morrison RS, Ahronheim JC, Morrison GR, Darling E, Baskin SA, Morris J, Choi C, Meier DE. Pain and discomfort associated with common hospital procedures and experiences. J Treatment of pain symptoms. 1998 February; 15(2):91-101. PMID:9494307

Nelson R, Tse B, Edwards S. Systematic review of prophylactic nasogastric decompression after abdominal operations. Br J Surg. 2005 Jun;92(6):673-80. doi: 10.1002/bjs.5090. PMID:15912492

Palamidessi N, Sinert R, Falzon L, Zehtabchi S. Nasogastric aspiration and lavage in emergency room patients with hematochezia or melena without hematemesis. Acad Emerg Med. 2010 February; 17(2): 126-32. doi: 10.1111/j.1553-2712.2009.00609.x. PMID:20370741

Paradis M. Towards evidence-based emergency medicine: Manchester Royal Infirmary's best bets. BET 1: Is routine nasogastric decompression indicated in small bowel occlusion? Emerg Med J. 2014 Mar;31(3):248-9. doi: 10.1136/emermed-2014-203617.1. PMID:24532357

Sarr MG, Sanfey H, Cameron JL. Randomized prospective study of nasogastric suction in patients with acute pancreatitis. Surgery. 1986 September; 100(3):500-4. PMID:3526610

Singer AJ, Konia N. Comparison of topical anesthetics and vasoconstrictors versus lubricants prior to nasogastric intubation: a randomized controlled trial. Acad Emerg Med. 1999 Mar;6(3):184-90. doi: 10.1111/j.1553-2712.1999.tb00153.x. PMID:10192668

Witting MD. "What do you want to do?!" Modern indications for nasogastric intubation. J Emerg Med. 2007 July; 33(1): 61-4. doi: 10.1016/j.khmermed.2007.02.017. Epub 2007 May 30. PMID:17630077

Photo byakyurt del motoraboutUnsplash

Cite this article as:
Morgenstern, J. NG Tubes for Small Bowel Obstruction: More Pain Than Evidence, First10EM, Aug 2, 2021. Available at:


How painful is an NG tube? ›

NG tubes are very painful. They are routinely rated as among the very worst things that we do to patients. It is possible to limit the pain associated with NG placement using topical lidocaine, although it is unclear how long the analgesic effect will persist, as these tubes are generally left in place for many days.

Can an NG tube fix a small bowel obstruction? ›

Most bowel obstructions are partial blockages that get better on their own. The NG tube may help the bowel become unblocked when fluids and gas are removed. Some people may need more treatment. These treatments include using liquids or air (enemas) or small mesh tubes (stents) to open up the blockage.

Is small bowel obstruction painful? ›

Signs and symptoms of intestinal obstruction include: Crampy abdominal pain that comes and goes. Loss of appetite.

How long does an NG tube stay in for small bowel obstruction? ›

Our protocol is as follows: Rule out ischemic obstruction (see “Zielinski signs” above) NG suction for at least 2 hours.

What are the pros and cons of nasogastric tube? ›

Pros: NG tubes are easy to insert at home or in the hospital and don't require surgery. They are easy to remove too, making them perfect for short-term feeding problems. Cons: NG tubes can cause irritation inside the nose, especially over long periods of time.

What are the disadvantages of NG tube? ›

NG tubes may lead to choking and discomfort, and when not inserted into the trachea properly, pneumonia can result. Such tubes have been known to cause erosions and abrasions within the nasal passages, stomach, and esophagus, which can cause bleeding.

How do you fix a small bowel obstruction without surgery? ›

Treatment includes intravenous (in the vein) fluids, bowel rest with nothing to eat (NPO), and, sometimes, bowel decompression through a nasogastric tube (a tube that is inserted into the nose and goes directly to the stomach). Anti-emetics: Medications may be required to relieve nausea and vomiting.

How do they fix a small bowel obstruction? ›

Surgery typically involves removing the obstruction, as well as any section of your intestine that has died or is damaged. Alternatively, your doctor may recommend treating the obstruction with a self-expanding metal stent.

Can small bowel obstruction be treated without surgery? ›

An intestinal obstruction is painful and potentially dangerous, and typically requires hospital care. However, you won't necessarily need surgery. Many blockages can be resolved with a non-invasive procedure, and patients often never have a recurrence.

How much does a bowel obstruction hurt? ›

Bowel obstructions usually cause cramping, abdominal pain, vomiting and inability to pass bowel motions (faeces or poo) or gas. A bowel obstruction is an emergency and needs treatment in hospital to prevent serious complications.

How long does it take to recover from small bowel obstruction surgery? ›

Most patients stay in the hospital for between five and seven days following bowel obstruction surgery. It can take several weeks or months to fully return to normal activities. Your medical team with work with you to manage post-surgical pain.

Where is small bowel pain located? ›

Signs and symptoms of small bowel disorders

You likely feel discomfort around the abdomen, rectum and lower belly. Symptoms may include: Diarrhea. Constipation.

How do you know when to stop using an NG tube? ›

Consider stopping tube feeding when the risks or burdens of the feeding are greater than possible benefit. Among the burdens of tube feeding is the possible discomfort that may be caused by the tubes. In addition, the feeds themselves may cause diarrhea, reflux, aspiration , and fluid overload.

How long can you stay on NG tube? ›

How long can an NG tube stay in? It's only designed to be used for up to six weeks. If you end up needing enteral nutrition for longer than that, your healthcare provider will recommend switching to another kind of feeding tube.

How do you prevent NG tube blockage? ›

To avoid clogged feeding tubes, flush gently.

Always flush the tube immediately before and after feeding with at least 30 mL (1 ounce) of water. Never mix medicine with tube feeding unless advised to do so by your healthcare practitioner. Flush tube with at least 30 mL of water before and after all medications.

What are alternatives to NG tubes? ›

Other options for replacement include Mic-Key, Pezzer, or Malecot gastrostomy tubes which can prevent side leakage at stoma site.

What are 3 complications of caring for the person with a nasogastric tube? ›

The most common complications related to the placement of nasogastric tubes are discomfort, sinusitis, or epistaxis, all of which typically resolve spontaneously with the removal of the nasogastric tube.

Is an NG tube uncomfortable? ›

Even though having an NGT put in is a short procedure and does not hurt, it is not very pleasant. Paracetamol or other medicines for pain relief will not stop the discomfort. Knowing what will happen during the procedure will help make it easier for you and your child.

What pain medicine is given for small bowel obstruction? ›

Morphine sulfate (Astramorph, MS Contin, Kadian, Duramorph) This is the drug of choice for analgesia due to its reliable and predictable effects, safety profile, and ease of reversibility with naloxone. Various IV doses are used; morphine sulfate is commonly titrated until the desired effect is obtained.

Can a small bowel obstruction be fatal? ›

Immediate treatment is needed to remove the blockage. This can relieve painful symptoms and prevent serious complications such as tissue death or rupture of the small bowel. Without treatment, a bowel obstruction can be fatal.

What is the most common cause of small bowel obstruction? ›

Small-bowel obstruction (SBO) is caused by a variety of pathologic processes. The most common cause of SBO in developed countries is intra-abdominal adhesions, accounting for approximately 65% to 75% of cases, followed by hernias, Crohn disease, malignancy, and volvulus.

How long can a person go with a bowel obstruction? ›

Without any fluids (either as sips, ice chips or intravenously) people with a complete bowel obstruction most often survive a week or two. Sometimes it's only a few days, sometimes as long as three weeks. With fluids, survival time may be extended by a few weeks or even a month or two.

What does a small bowel obstruction feel like? ›

Loss of appetite. New or worsening abdominal pain. Severe abdominal distension, bloating or swelling. You are unable to have a bowel movement or pass gas.

Are small bowel obstructions always surgical? ›

For a total mechanical blockage, surgery will most likely be required. Most bowel obstructions will need some form of hospital intervention to relieve the problem. If you suspect that you have a bowel obstruction, you should seek medical advice as soon as possible to avoid the situation becoming life-threatening.

How do you prevent recurrence of small bowel obstruction? ›

Chew foods well. Eat in a relaxed setting and eat slowly. Eat smaller amounts of food more often throughout the day. Drink 2000 to 2500 mL (8 to 10 cups) of fluids every day.

Can a small bowel obstruction come back? ›

Recurrence is common, occurring in approximately 20% of patients. Previous studies have suggested that nonoperative management of SBO may be associated with a greater risk of recurrence than operative management.

What happens after small bowel obstruction surgery? ›

You will be in the hospital for 3 to 7 days. You may have to stay longer if your surgery was an emergency operation. You also may need to stay longer if a large amount of your small intestine was removed or you develop problems. By the second or third day, you will most likely be able to drink clear liquids.

Where is the pain with a bowel obstruction? ›

An intestinal blockage happens when something blocks your intestine. If the intestine is completely blocked, it is a medical emergency needing immediate attention. Symptoms of an intestinal blockage include severe belly pain or cramping, vomiting, not being able to pass stool or gas, and other signs of belly distress.

What does the ER do for bowel obstruction? ›

Initial emergency department (ED) treatment of small-bowel obstruction (SBO) consists of aggressive fluid resuscitation, bowel decompression, administration of analgesia and antiemetic as indicated clinically, early surgical consultation, and administration of antibiotics.

What is the most common complication of small bowel obstruction? ›

Hernias — probably the most common condition in children and adults, in which a small part of the intestine protrudes through another part of the body.

Why does my small bowel hurt? ›

Problems with the small intestine can cause not only discomfort but also nutritional problems, and this can affect the rest of the body. Diseases and conditions that can affect the small intestine include Crohn's disease, celiac disease, small intestinal bacterial overgrowth (SIBO), and irritable bowel syndrome (IBS).

What medications cause bowel obstruction? ›

  • Opioid pain relievers. Also called narcotics, opioids treat pain that is severe and that has not improved with other, milder pain medications. ...
  • NSAIDs. ...
  • Antihistamines. ...
  • Tricyclic antidepressants. ...
  • Urinary incontinence medications. ...
  • Iron supplements. ...
  • Blood pressure medications. ...
  • Anti-nausea medications.
Feb 10, 2020

What happens if your bowel hurts? ›

Painful poops may just be a temporary case of diarrhea, constipation, or hemorrhoids that go away in a few days — none of these causes are usually serious. See your doctor if bowel movements are painful for a few weeks or the pain is sharp and intense enough to disrupt your everyday life.

Can an NG tube burst? ›

These case reports suggest that a small gastric remnant may be a risk factor for nasogastric tube coiling and knot formation and that flushing a clogged tube at high pressure may rupture it.

How can I make my NG tube more comfortable? ›

Keep the tube in the area of the nostril taped to the nose. Make sure that the hanging part of the tube is pinned on your clothes. This will decrease the stress produced by the weight of the rest of the NG tube.

Why are NG tubes not used long term? ›

Although nasogastric tube feeding (NGT) is a time-proven technique for enteral nutrition, it should not be used for more than 4–6 weeks because of complications or poor adherence to treatment [10, 11].

What is the most common problem in tube feeding? ›

The most common reported complication of tube feeding is diarrhea, defined as stool weight > 200 mL per 24 hours.

What does getting an NG tube feel like? ›

The insertion started

I could feel a gentle but consistent pain when the tube was going through my nostril and going down to the back of my throat. I could feel this foreign body in my throat and the urge was either to swallow or spit it out.

Are you sedated for NG tube? ›

Midazolam (Versed) is an FDA-approved agent for procedural sedation, which has been used frequently at this institution for the placement of NG tubes in the emergency department.

Does getting a feeding tube put in Hurt? ›

They're often used if the need is temporary. You'll need surgery for the other types of tubes. A feeding tube can be uncomfortable and even painful sometimes. You'll need to adjust your sleeping position and make extra time to clean and maintain your tube and to handle any complications.

Are you awake for NG tube placement? ›

NG tubes are usually placed at the bedside while the patient is awake. It is important for patients to breathe normally and stay relaxed during the procedure. Swallowing air or water through straw can help advance the tube to its proper position.

When should you not insert an NG tube? ›

Nasogastric (NG) tubes can be easily displaced. If you are concerned the tube is not in the stomach and/or the pH strip indicates a reading of more than 5.5, do not put anything down the tube.

What tube is used for bowel obstruction? ›

Nasogastric tubes are part of the standard of care in treating intestinal obstruction and can also be used to provide nutritional support. They are most common in surgical patients but are useful in any patient population where gastric decompression or nutritional support is necessary.

Is an NG tube serious? ›

Nasogastric tubes pose very few risks when used correctly, but there is the possibility of side effects. Common complications include discomfort from placing and removing the tubes, sinusitis, or epistaxis. When placed incorrectly, tubes may puncture your child's esophageal tissue, make a hole, and cause damage.

Is NG tube considered life support? ›

Tube feeding is not considered a basic part of care. Health care providers, ethicists and the courts consider it to be artificial nutrition and a medical treatment. This makes it comparable to other medical treatments such as dialysis or assisted breathing.

How long does a feeding tube hurt? ›

Your belly may feel sore, like you pulled a muscle, for several days. Your doctor will give you pain medicine for this. It will take about a week for the skin around your feeding tube to heal. You may have some yellowish mucus where the feeding tube comes out of your belly.

Is there an alternative to a feeding tube? ›

A: Though it is much more time-consuming, hand feeding appears to be a better alternative than tube feeding for older adults with advanced dementia. Tube feeding probably reduces the risk that food will end up in the lungs and cause pneumonia.

What happens if a NG tube is placed incorrectly? ›

The most serious harm from NG tube placement arises from misplaced NG tubes, when the tip is lying in the lungs or the pleural space, leading to pneumothorax, pneumonia and feed empyema, which can be fatal if not recognised early. This occurs in 1-3% of blind NG tube placements.


Top Articles
Latest Posts
Article information

Author: Tyson Zemlak

Last Updated: 07/08/2023

Views: 6615

Rating: 4.2 / 5 (43 voted)

Reviews: 82% of readers found this page helpful

Author information

Name: Tyson Zemlak

Birthday: 1992-03-17

Address: Apt. 662 96191 Quigley Dam, Kubview, MA 42013

Phone: +441678032891

Job: Community-Services Orchestrator

Hobby: Coffee roasting, Calligraphy, Metalworking, Fashion, Vehicle restoration, Shopping, Photography

Introduction: My name is Tyson Zemlak, I am a excited, light, sparkling, super, open, fair, magnificent person who loves writing and wants to share my knowledge and understanding with you.