An unusual complication of nasogastric tube

Multiple case reports of complications of malposi- tioned feeding tubes continue to surface. Most are due to inadvertent placement in the respiratory tract. Isolated reports of a nasally placed tube entering the brain follow- ing head injury continue to occur, as do reports of esophageal and gastric perforation in neonates. A recent study showed that malpositioned tubes are not routinely recorded in risk management databases (1). But maybe the most important complication of nasogastric tubes (NGT) is GI bleeding. It has been reported that pro- longed use of NGT can even result in life-threatening aortoesophageal fistula formation in patients with a double aortic arch (2). Herein we report a case with a buried NGT and GI hemorrhage after the unsuccessful attempt to remove the NGT.