Severe epistaxis after nasogastric tube insertion requiring arterial embolisation

Abstract

A 53-year-old dialysis patient was admitted with symptoms of a respiratory tract infection, abdominal pain and vomiting. She aspirated and required intubation. A nasogastric tube was placed with slight difficulty and the patient developed severe epistaxis. The bleeding could not be controlled with mechanical pressure and nasal packing. Angiography revealed extravasation from a pseudoaneurysm arising from the inferior pharyngeal branch of the ascending pharyngeal trunk. The vessel was successfully embolised with cessation of bleeding. We emphasise that even a seemingly easy procedure like insertion of a nasogastric tube, can lead to a life-threatening complication.

Background

Nasogastric tube insertion is one of the most commonly performed procedures on hospitalised patients. It is performed by medical staff with varying degrees of expertise including residents, medical students, nurses and nurse practitioners. It is a safe procedure with a low complication rate, but minor complications are not uncommon. Occasionally it can cause a severe life-threatening complication that needs to be identified and treated promptly.

Case presentation

A 53-year-old woman with a medical history of end-stage renal disease, hypertension and type 2 diabetes mellitus was sent from the dialysis centre because of fever, shortness of breath, abdominal pain and vomiting. She had a temperature of 102.8°F, heart rate of 112 beats/min and a blood pressure of 110/60 mm Hg. Her initial laboratory values showed a leukocytosis of 18 000/μl with predominant neutrophils and a haematocrit of 30%. There was no coagulopathy. A CT scan with per os contrast of chest/abdomen was ordered. She ingested the contrast, vomited and aspirated which resulted in respiratory distress requiring intubation. A nasogastric tube was placed for gastric decompression. Although there was some resistance on the first attempt, it passed easily on the second attempt. The patient, however, started to bleed profusely from both nostrils. Since the bleeding could not be controlled with a combination of mechanical pressure, anterior and posterior nasal packing an angiogram of the common carotids was performed.

Investigations

An angiogram of the common carotid arteries with neck views was urgently performed. It demonstrated extravasation from a pseudoaneurysm arising from the right inferior pharyngeal branch of the ascending pharyngeal trunk (figure 1). The remainder of the head and neck circulation was normal.

Figure 1.

Extravasation from a pseudoaneurysm arising from the inferior pharyngeal branch of the ascending pharyngeal trunk.

Treatment

Patient underwent embolisation of the pseudoaneurysm by interventional radiology. Thirty per cent liquid acrylic was injected into the vessel under fluoroscopic guidance using a microcatheter. A repeat angiogram was performed demonstrating no further evidence of extravasation (figure 2).

Figure 2.

A repeat angiogram demonstrating no further evidence of extravasation.

Outcome and follow-up

There was no further bleeding after the procedure. She was admitted to the medical intensive care unit where she received intravenous antibiotics and was successfully extubated after 3 days. She was discharged after 8 days of hospitalisation.

Discussion

Potential complications after nasogastric tube placement include nasal bleeding secondary to trauma, malpositioning and gastric erosions.¹ Most of the complications are minor and resolve without significant therapy. Rarely life-threatening complications can occur. They may include rupture of the cribriform plate, perforation of the stomach and serious bleeding like our patient had. Our patient bled from a pseudoaneurysm arising from the inferior pharyngeal branch of the ascending pharyngeal trunk.

The ascending pharyngeal artery is a branch of external carotid artery and may be involved in trauma, high-grade head and neck tumours and vascular lesions.² Very rarely, it can be a source of epistaxis like in our patient. Superselective embolisation is the treatment of choice for this bleeding.³

This case demonstrates a rare cause of epistaxis after nasogastric tube placement that originated from the inferior branch of the pharyngeal trunk of the ascending pharyngeal artery. It also emphasises the need for caution when performing any procedure no matter how minor.

Learning points.

• Nasogastric tube insertion can sometimes lead to very serious complications, and prompt recognition and treatment are required.

• Pseudoaneurysms may form in vessels due to the trauma caused by the tube.

• Embolisation of the bleeding vessel may be required to control the bleeding.