Clinical presentation An elderly female patient was admitted to intensive care for prolonged vasopressor therapy and mechanical ventilation after cardiac arrest and acute percutaneous coronary intervention. Antiplatelet, thyroid hormone replacement and statin therapies were administered through a 14-French nasogastric tube (Nestlé Health Science) and enteral feeding was initiated. Correct position of the nasogastric tube was confirmed radiologically. On the seventh day in the intensive care, our patient was seen to regurgitate soft crumbs into her mouth. The blocked nasogastric tube was removed, but attempts to reinsert another tube failed.
Upper GI endoscopy revealed an obstruction of the oesophagus with a milky-yellowish caseous substance 20 cm from the incisors (figure 1). The proximal part of the mass showed a central hole and ring-shaped layers resembling the cut face of a tree trunk.
Questions What caused the obstruction?
How should we manage such a problem?
- oesophageal disorders
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This case describes a rare complication of enteral feeding in critically ill patients: the development of an enteral nutrition bezoar in the oesophagus with subsequent oesophageal obstruction. The main pathogenic factor for solidification of enteral nutrition is precipitation of casein present in the feeding supplement at a low pH.1 Other risk factors for this complication include presence of gastro-oesophageal reflux, disrupted oesophageal and GI motility, or simultaneous administration of sucralfate.2 3 Our patient did not receive sucralfate and did not show hiatal hernia or evidence of gastro-oesophageal disease. In critical care patients, however, some degree of reflux is unavoidable due to the influence on oesophageal motility of mechanical ventilation, as well as sedatives and relaxants. As displayed in figure 1, the bezoar’s ring shape suggests temporary reflux with gradual solidification around the nasogastric tube.
In our case, we were able to push the formation to the stomach (figure 2A), where it was crushed with biopsy forceps and removed piece by piece using an extraction basket. The reassembly of some extracted parts and the nasogastric tube is presented in figure 2B. The total length of the cylindrical bezoar was about 15 cm. When the bezoar is impacted within the oesophagus, pepsin or pancreatic enzymes may be used in an attempt to dissolve it.4 Measures such as administration of proton pump inhibitors or prokinetic agents, elevation of the patient’s head or feeding with casein-free solutions might prevent the development of this rare complication of enteral feeding in critically ill patients.2
Contributors FR, GP, LPB, PF and JP: design, acquisition of data and drafting of manuscript.
Competing interests None declared.
Provenance and peer review Not commissioned; externally peer reviewed.
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