Gastric lavage

Reviewed and revised 7th August 2013

OVERVIEW

• Gastric lavage is a gastrointestinal decontamination technique that aims to empty the stomach of toxic substances by the sequential administration and aspiration of small volumes of fluid via an orogastric tube.
• previously widely favoured method that has now been all but abandoned due to lack of evidence of efficacy and risk of complications.

INDICATIONS

Gastric lavage should be rarely, if ever, performed.

• The amount of toxin removed by gastric lavage is unreliable and often negligible, especially if performed after the first hour.
• There are few (if any) situations where the expected benefits of gastric lavage would exceed the risks involved and where administration of activated charcoal would not be provide equal or greater efficacy of decontamination.

TECHNIQUE

•  Perform in an appropriately staffed and equipped resuscitation area
• Do not perform in any patient with an impaired level of consciousness unless the airway is protected by a cuffed endotracheal tube
• Position the patient in the left decubitus position with 20° head down
• Measure the length of tube required to reach the stomach externally before beginning the procedure
• Pass a large bore 36-40 G lubricated lavage tube extremely gently down the oesophagus. Stop if any resistance occurs
• Confirm tube position by aspirating gastric contents and auscultating for insufflated air at the stomach; consider CXR for confirmation of position
• Administer a 200 mL aliquot of warm tap water or normal saline into the stomach via the funnel and lavage tube
• Drain the administered fluid into a dependent bucket held adjacent to the bed
• Repeat administration and drainage of fluid aliquots until the effluent is clear
• Activated charcoal 50 g may be administered via the tube once lavage complete.

CONTRAINDICATIONS

• Initial resuscitation incomplete
• Risk assessment indicates good outcome with supportive care and antidote therapy alone
• Unprotected airway where there is a decreased level of consciousness or risk assessment indicates potential for these complications during the procedure
• Small children
• Corrosive ingestion
• Hydrocarbon ingestion

COMPLICATIONS

• Incomplete decontamination leading to severe intoxication despite the procedure
• Pulmonary aspiration
• Hypoxia
• Laryngospasm
• Mechanical injury to the gastrointestinal tract
• Water intoxication (especially in children)
• Hypothermia
• Distraction of staff from resuscitation and supportive care priorities

EVIDENCE

• most studies are low quality or methodological flawed
• no published data suggests that gastric lavage forces poison into the small bowel
• animal and volunteer studies suggest variable and incomplete return of ingested agents following gastric lavage (generally <50%), even after 15 minutes with rapid decline at 1 hour
• various case reports suggest recovery of ingested tablets with gastric lavage, especially in situations where gastric emptying may be delayed (e.g. hypothermia, anticholinergic syndrome), but there is no evidence that this changes outcome
• no trials have shown benefit of gastric lavage over activated charcoal, except for the subset of obtunded patients at >1hour in one methodologically flawed study (Kulig et al, 1985)

HISTORICAL PERSPECTIVE

• Gastric lavage was first described in 1822 in London: Jukes’ “exhausting pump” and Bush’s “gastric exhauster”, primarily used for opium ingestion
• The heyday was in the 1950s and 1960s when gastric lavage was the method of choice for all but first aid settings, and for almost all significant poisonings. At this time barbiturate poisoning was rife and most objective studies took place in this context
• Pediatricians led the way in turning from gastric lavage, due to inherent difficulties in performing the procedure on children
• Position statements from the AACT and their European counterparts in 1994, 2003 and 2013 have, in essence, recommended that procedure be abandoned
• The procedure is still widely performed in developing countries, including India and Sri Lanka, partly because case fatality rates are higher (10-20% versus 0.5% in the West), other therapeutic options may be unavailable and because of entrenched dogma

THE ARGUMENT FOR GASTRIC LAVAGE

Some experts argue that there is still a role for gastric lavage if the following criteria are met:

• staff are familiar with the procedure
• the patient is likely to die despite other therapies
• drug is still in the stomach (i.e. very early after ingestion)
• tablets will fit up a tube
• airway is protected (i.e. intubated)

However, such a situated is vanishingly rare (e.g. massive colchicine overdose) and would likely require the intubation of asymptomatic patients almost immediately after ingestion.

For a discussion in the context of tricyclic overdose, see the comments discussing Toxicology Conundrum 022.

References and Links

LITFL

• CCC — GI Decontamination

Journal articles and textbooks

• Albertson TE, Owen KP, Sutter ME, Chan AL. Gastrointestinal decontamination in the acutely poisoned patient. Int J Emerg Med. 2011 Oct 12;4:65. PMC3207879.
• Benson BE, Hoppu K, Troutman WG, Bedry R, Erdman A, Höjer J, Mégarbane B, Thanacoody R, Caravati EM. Position paper update: gastric lavage for gastrointestinal decontamination. Clin Toxicol (Phila). 2013 Feb 18. [PMID: 23418938.
• Eddleston M, Haggalla S, Reginald K, Sudarshan K, Senthilkumaran M, Karalliedde L, Ariaratnam A, Sheriff MH, Warrell DA, Buckley NA. The hazards of gastric lavage for intentional self-poisoning in a resource poor location. Clin Toxicol (Phila). 2007;45(2):136-43. PMC1941903.
• Eddleston M, Juszczak E, Buckley N. Does gastric lavage really push poisons beyond the pylorus? A systematic review of the evidence. Ann Emerg Med. 2003 Sep;42(3):359-64. PMID: 12944888.
• Kulig K, Bar-Or D, Cantrill SV, Rosen P, Rumack BH. Management of acutely poisoned patients without gastric emptying. Ann Emerg Med. 1985 Jun;14(6):562-7. PMID: 2859819.
• Proudfoot AT. Abandon gastric lavage in the accident and emergency department? Arch Emerg Med. 1984 Jun;1(2):65-71. PMC1285201.
• Pond SM, Lewis-Driver DJ, Williams GM, Green AC, Stevenson NW. Gastric emptying in acute overdose: a prospective randomised controlled trial. Med J Aust. 1995 Oct 2;163(7):345-9. PMID: 7565257.

FOAM and web resources

• EMN — Myths of Toxicology: Gastric Lavage (2009)
• TPR — Gastric lavage? Fuggedaboutit! (2013)
• Twitter conversation started by @PharmERToxGuy 6 Dec 2012