Nasogastric Aspiration and Lavage in Emergency Department Patients with Hematochezia or Melena Without Hematemesis

Abstract

Objectives: The utility of nasogastric aspiration and lavage in the emergency management of patients with melena or hematochezia without hematemesis is controversial. This evidence-based emergency medicine review evaluates the following question: does nasogastric aspiration and lavage in patients with melena or hematochezia and no hematemesis differentiate an upper from lower source of gastrointestinal (GI) bleeding?Methods: MEDLINE, EMBASE, the Cochrane Library, and other databases were searched. Studies were selected for inclusion in the review if the authors had performed nasogastric aspiration (with or without lavage) in all patients with hematochezia or melena and performed esophagogastroduodenal endoscopy (EGD) in all patients. Studies were excluded if they enrolled patients with history of esophageal varices or included patients with hematemesis or coffee ground emesis (unless the data for patients without hematemesis or coffee ground emesis could be separated out). The outcome was identifying upper GI hemorrhage (active bleeding or high-risk lesions potentially responsible for hemorrhage) and the rate of complications associated with the nasogastric tube insertion. Quality of the included studies was assessed using standard criteria for diagnostic accuracy studies.Results: Three retrospective studies met our inclusion and exclusion criteria. The prevalence of an upper GI source for patients with melena or hematochezia without hematemesis was 32% to 74%. According to the included studies, the diagnostic performance of the nasogastric aspiration and lavage for predicting upper GI bleeding is poor. The sensitivity of this test ranged from 42% to 84%, the specificity from 54% to 91%, and negative likelihood ratios from 0.62 to 0.20. Only one study reported the rate complications associated with nasogastric aspiration and lavage (1.6%).Conclusions: Nasogastric aspiration, with or without lavage, has a low sensitivity and poor negative likelihood ratio, which limits its utility in ruling out an upper GI source of bleeding in patients with melena or hematochezia without hematemesis. ACADEMIC EMERGENCY MEDICINE 2010; 17:126-132 ª 2010 by the Society for Academic Emergency MedicineKey words: gastrointestinal hemorrhage, melena, hematochezia, nasogastric aspiration CLINICAL SCENARIOA 75-year-old African American male with the chief complaint of bright red blood per rectum is brought to your emergency department (ED) via ambulance. The paramedics state that they observed a toilet bowl filled with red blood without clots. The patient appeared to the paramedics in no acute distress, with initial vital signs of blood pressure (BP) 160 ⁄ 95 mm Hg, pulse rate (PR) 90 beats ⁄ min, and respiratory rate (RR) 18 breaths ⁄ min. At triage the patient is alert and oriented and appears in no acute distress. The blood appears mixed with stool during three episodes. The patient denies hematemesis or any associated abdominal pain. He denies previous episodes of similar bleeding and has no history of esophageal varices, chr...

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