Nasogastric or Intestinal Intubation
Nasogastric or intestinal intubation is used to decompress the stomach. It is used to treat gastric atony, ileus, or obstruction; remove ingested toxins, give antidotes (eg, activated charcoal), or both; obtain a sample of gastric contents for analysis (volume, acid content, blood); and supply nutrients.
Esophageal varices previously have been considered a contraindication, but evidence of adverse effects is lacking.
Several types of tubes are available. A Levin or Salem sump tube is used for gastric decompression or analysis and rarely for short-term feeding. A variety of long, thin, intestinal tubes are used for long-term enteral feeding (see Nutritional Support: Enteral Tube Nutrition).
For intubation, the patient sits upright or, if unable, lies in the left lateral decubitus position. A topical anesthetic sprayed in the nose and pharynx helps reduce discomfort. With the patient's head partially flexed, the lubricated tube is inserted through the nares and aimed back and then down to conform to the nasopharynx. As the tip reaches the posterior pharyngeal wall, the patient should sip water through a straw. Violent coughing with flow of air through the tube during respiration indicates that the tube is misplaced in the trachea. Aspiration of gastric juice verifies entry into the stomach. The position of larger tubes can be confirmed by instilling 20 to 30 mL of air and listening with the stethoscope under the left subcostal region for a rush of air.
Some smaller, more flexible intestinal feeding tubes require the use of stiffening wires or stylets. These tubes usually require fluoroscopic or endoscopic assistance for passage through the pylorus.
Complications are rare and include nasopharyngeal trauma with or without hemorrhage, pulmonary aspiration, traumatic esophageal or gastric hemorrhage or perforation, and (very rarely) intracranial or mediastinal penetration.
Anoscopy and Sigmoidoscopy
Anoscopy and sigmoidoscopy are used to evaluate symptoms referable to the rectum or anus (eg, bright rectal bleeding, discharge, protrusions, pain). In addition, sigmoidoscopy also allows for biopsy of colonic tissues and application of intervention such as hemostasis or intraluminal stenting. There are no absolute contraindications, except those for regular endoscopies should be considered. Patients with cardiac arrhythmias or recent myocardial ischemia should have the procedure postponed until the comorbid conditions improve; otherwise, patients will need cardiac monitoring. Per changes in American Heart Association guidelines, these procedures no longer require endocarditis prophylaxis.
The perianal area and distal rectum can be examined with a 7-cm anoscope, and the rectum and sigmoid can be examined with a rigid 25-cm or a flexible 60-cm instrument. Flexible sigmoidoscopy is much more comfortable for the patient and readily permits photography and biopsy of tissue. Considerable skill is required to pass a rigid sigmoidoscope beyond the rectosigmoid junction (15 cm) without causing discomfort.
Sigmoidoscopy is done after giving an enema to empty the rectum. IV drugs are usually not needed. The patient is placed in the left lateral position. After external inspection and digital rectal examination, the lubricated instrument is gently inserted 3 to 4 cm past the anal sphincter. At this point, the obturator of the rigid sigmoidoscope is removed, and the instrument is inserted further under direct vision.
Anoscopy may be done without preparation. The anoscope is inserted its full length as described above for rigid sigmoidoscopy, usually with the patient in the left lateral position. Complications are exceedingly rare when the procedure is done properly.
Abdominal paracentesis is used to obtain ascitic fluid for testing. It also can be used to remove tense ascites causing respiratory difficulties or pain or as a treatment for chronic ascites.
Absolute contraindications include
Poor patient cooperation, surgical scarring over the puncture area, large intra-abdominal masses, and severe portal hypertension with abdominal collateral circulation are relative contraindications.
CBC, platelet count, and coagulation studies are done before the procedure. After emptying the bladder, the patient sits in bed with the head elevated 45 to 90°. In patients with obvious and marked ascites, a point is located at the midline between the umbilicus and the pubic bone and is cleaned with an antiseptic solution and alcohol. Two other possible sites for paracentesis are located about 5 cm superior and medial to the anterior superior iliac spine on either side. In patients with moderate ascites, precise location of ascitic fluid by abdominal ultrasound is indicated. Positioning the patient in a lateral decubitus position with the planned insertion site down also promotes the floating and migration of air-filled bowel loops up and away from the point of entry. Under sterile technique, the area is anesthetized to the peritoneum with lidocaine 1%. For diagnostic paracentesis, an 18-gauge needle attached to a 50-mL syringe is inserted through the peritoneum (generally a popping sensation is noted). Fluid is gently aspirated and sent for cell count, protein or amylase content, cytology, or culture as needed. For therapeutic (large-volume) paracentesis, a 14-gauge cannula attached to a vacuum aspiration system is used to collect up to 8 L of ascitic fluid. Concurrent infusion of IV albumin is recommended during large-volume paracentesis to help avoid significant intravascular volume shift and postprocedural hypotension.
Hemorrhage is the most common complication. Occasionally, with tense ascites, prolonged leakage of ascitic fluid occurs through the needle site.
Last full review/revision February 2013 by Walter W. Chan, MD, MPH