Chapter 49

Gastric lavage is a method of gastrointestinal decontamination, performed in the setting of an ingested overdose or acute poisoning, to decrease the absorption of substances in the stomach. This technique was first described in 1812 and has been used for nearly 200 years.1 It was repopularized in the 1950s and 1960s and thrived during the heyday of the “tricyclic era” of the 1970s. Gastric lavage has had a diminishing role in modern toxicology for several reasons. Most notable is the trend toward evidence-based medicine and the growing body of data pointing to the limited efficacy of gastric lavage. The increasing use of other modalities for gut decontamination (e.g., activated charcoal, whole bowel irrigation) has further limited the role of gastric lavage.1,2

Gastric lavage remains the decontamination modality of choice in a few particular situations. This includes highly toxic or potentially lethal ingestions that present acutely and where no antidotal or other therapies are available. If timed and performed appropriately, this technique can significantly reduce the amount of ingestant available for absorption and thus effectively decrease the total dose absorbed.2 Gastric lavage has shown greatest benefit if performed promptly and within 1 to 2 hours of an oral ingestion. Efficacy appears greatest in the highest-risk ingestions.

The optimal timing of gastric lavage is controversial. All authors agree that the sooner it is instituted, the better. In volunteer and overdose studies, the range of recovered ingestant is broad at each time point following an ingestion. The trend for mean removal of ingestants is 90 percent recovery at 5 minutes postingestion, 45 percent recovery at 10 minutes, 30 percent recovery at 19 minutes, and as little as 8 percent recovery at 60 minutes.2

Undoubtedly, the efficacy of gastric lavage diminishes rapidly over time. Some toxicants or coingestants may cause delayed gastric emptying, while others may form masses or concretions in the stomach. Removal of only a small percentage of the ingested dose may be lifesaving or may avoid permanent sequelae in some cases. A reasonable approach is to consider gastric lavage in the acutely poisoned patient when it can be performed within 1 to 2 hours of a toxic or hazardous ingestion. The decision should be made with consideration to the specifics of the ingestion. Delayed gastric lavage may be indicated in a severely toxic poisoning or where delayed gastric emptying is suspected (e.g., anticholinergic or opioid coingestant). It may be useful to consult a poison control center or a medical toxicologist in borderline or difficult cases.

Nasogastric placement of a gastric lavage tube is generally not indicated. The orogastric route should be used to avoid injury to the nasal mucosa, nasal turbinates, and nasal septum. The use of a small-bore nasogastric tube is discouraged if the objective is gastric emptying. If an appropriately sized nasogastric tube is placed for other reasons and if the ingestant is in liquid form, aspiration of ...

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