Vol.3, No.7, 401-405 (2011)
Copyright © 2011 SciRes. Openly accessible at http://www.scirp.org/journal/HEALTH/
Safety of gastric lavage using nasogastric ryle’s tube in
pesticide poisoning
Uday Bhan Bhardwaj, Anand Subramaniyan, Ashish Bhalla, Navneet Sharma, Surjit Singh*
Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India; *Corresponding
Author: surjit51@hotmail.com, surjit51200@yahoo.co.in
Received 13 April 2011; revised 1 June 2011; accepted 10 June 2011.
Objective: Gastric lavage is mandatory irre-
spective of nature in all patients w ith acute poi-
soning in India. Present study was undertaken
with aim whether lavage done using naso-ga-
stric Ryle’s tube and small aliquots of water or
normal saline is safe. Patients and Methods: All
the patients above 12 years of age admitted
consecutively with pesticide ingestion or ex-
posure between July 2004 to June 2005 were
studied with respect to complications associ-
ated with lavage using Ryle’s tube. Forty five
patients were admitted directly to our hospital
and lavage was undertaken using Ryle’s tube
(16F ) with 100 - 200 mL of aliquots till 1 - 1.5
liters of fluid was lavaged, with prophylactic
endotracheal intubation in patients with Glas-
gow coma scale ( GCS) < 10 (group I). The inci-
dence of complications related to lavage in
group I was compared to that in 53 patients
admitted during same period with pesticide
poisoning but lavaged outside using naso-
gastric Ryle’s tube and referred to our institute
(group II). Results: The significant complica-
tions observed in group I were significant drop
in SaO2 (6 patients) laryngospasm, tachycardia,
electrolyte imbalance and tube getting struck in
throat (one each). In one patient in group I (had
no prophylactic intubation though GCS 3) In
group II, 7 had aspiration pneumonia (no pro-
phylactic intubation). Other significant compli-
cation was drop in SaO2 during lavage. None of
them had any serious life threatening complica-
tion. Conclusion: Gastric lavage carried out us-
ing naso-gastric Ryle’s tube and small aliquots
of water or normal saline is relatively safe in
patients with pesticide poisoning when com-
bined with prophylactic endotracheal intubation
in patients with GCS < 10. In absence of pro-
phylactic intubation, risk of aspiration is there.
However aspiration pneumonia is generally mild
and not life threatening.
Keywords: Pesticide Poisoning; Gastric Lav age;
Nasogastric Ryle’s Tube; Complicat ions
Gastric lavage has to be carried out by treating physi-
cian in all patients with acute poisoning in India irre-
spective of nature, severity of poisoning and time inter-
val between ingestion and arrival to hospital as lavage
sample has to be provided to legal authorities in addition
to blood, urine and other samples. As per Indian penal
code (I.P.C,1973), the attending physician should collect,
preserve and seal the evidence related to the case of poi-
soning such as the gastric lavage fluid, vomiting, faeces,
urine etc. for onward transmission to forensic science
laboratory for chemical analysis. If doctor deliberately
fails to do so he is liable to be punished under section of
201 of I.P.C i.e. causing disappearance of evidence of
offence or giving false information to screen offender [1].
This is punishable with imprisonment up to 7 years or
fine or both. As per Indian law, attempt to commit sui-
cide is an offence under section 309 of I.P.C which states
that whoever attempts to commit suicide and does any
act towards the commission of such offence, shall be
punished with simple imprisonment for a term which
may extend to one year or with fine or wi t h both [2].
This is in contrast to developed countries where sui-
cide is not a criminal offence and lavage is rarely carried
out as there is no evidence that it is effective at all [3-7]
and can lead to significant morbidity and mortality [3,8 ].
Moreover in developed countries unlike developing
countries, drug overdoses are commonest form of poi-
soning [4]. These carry a low case fatality ratio due to
availability of effective antidotes and patients being ma-
naged in well equipped hospitals [4-7]. This is unlike
developing countries including India, where pesticide
U. B. Bhardwaj et al. / Health 3 (2011) 401-405
Copyright © 2011 SciRes. Openly accessible at http://www.scirp.org/journal/HEALTH/
poisoning is the commonest [9-11]. These cases carry
high case fatality ratio as specific antidotes eith er do n ot
exist or unavailable or unaffordable or only partially
effective [11,12]. As gastric lavage in case of poisoning
is necessary due to legal reasons in India [1,2] and as
studies regarding its safety in pesticide poisoned patients
do not ex ist [13], th e pr esent stu d y was undertak en using
naso-gastric Ryle’s tube with lavage being carried out,
using 100 - 200 mL aliquots of water or normal saline
till 1 - 1.5 liters are lavaged, to find its safety. The study
was not designed to determine whether gastric lavage
removes poison adequately or not.
All the patients age 12 or more consecutively admitted
to emergency medical services of Nehru Hospital at-
tached to Postgraduate Institute of Medical Education
and Research, Chandigarh (India) who had ingested or
were accidentally exposed to pesticides and reached our
hospital with in 24 hrs were included in the study be-
tween July 2004 to June 2005. The patien ts were div ided
into 2 groups. Group I included patients with pesticide
poisoning who reached our hospital directly and were
lavaged by a nurse under supervision of a medical resi-
dent or by medical resident. Group II comprised patients
who had consumed or exposed to pesticides and had
undergone lavage outside our hospital using naso-gastric
Ryle’s tube and were then referred to us for further
management. Only those patients who had symptoms
and signs consistent with pesticide poisoning were in-
cluded in study and all other poisoned patients were ex-
In group I, gastric lavage was carried out with na-
sogastric Ryle’s tube (16F) and using 100 - 200 mL ali-
quots of water or normal saline at a time till 1 - 1.5 liters
of lavage was completed. Prophylactic endotracheal in-
tubation was carried out in patients with GCS < 10. In
addition to measuring SaO2 by pulse oximeter, arterial
blood gases (ABG) were measured before, during and
after lavage. In those, where ABG could not be done,
SaO2 was continuously determined by pulse oximeter
alone. In addition continuous cardiac monitoring was
done. A chest x-ray was undertaken before and 4 hours
after lavage. Serum electrolytes (Na+, K+, Mg+ were
measured before and 4 hours after lavage. In group II
patients, no lavage was undertaken in our hospital and
they were assessed for any complications related to it. It
was not possible to know the exact amount of water or
normal saline they were lavaged with. However fro m the
hospitals they were referred to us, we checked the lavage
practices and it was found that lavage is undertaken
generally using smaller aliquots after passing naso-gas-
tric Ryle’s tube and fluid volume used generally does not
exceed 2 liters.
We could not undertake any tests to find how much
compound was removed by lavage from stomach or
from blood. The complication rate was determined by
determining percentages with confidence interval. The
groups were compared using Student t-test. Where ever
possible we tried to take patient’s consent though it is
not necessary as procedure being required by law. The
study plan was approved by the ethics committee of the
A total of 131 patients with acute poisoning were ad-
mitted during this period to our medical emergency. Of
these, 98 had history of ingestion or exposure to pesti-
cides and had toxidrome consistent with it. In group I,
there were 45 patien ts. In group II, of 54 one had under-
gone lavage outside with orogastric tube and was ex-
cluded. Thus 98 patients fulfilled the criteria for inclu-
sion in two groups and were taken up for final analysis.
Of 45 patients in group I, 40 had ingested with suicidal
intent and in 5 poisoning was alleged accidental expo-
sure during spraying (they were found unconscious, in-
gestion could no t be ruled out). Of 53 in group II, 46 had
ingested with suicidal intent where as 6 patients were
exposed accidentally during spray (as they were found
unconscious, ingestion could not be ruled out). In one,
circumstances could not be known. In group I, of 11
patients who had GCS < 10, prophylactic endotracheal
intubation was undertaken in 10. In 1 patient with GCS
of 3, medical resident failed to intubate the patient and
lavage was under taken. None in group II had prophylac-
tic endotracheal intu bation.
The mean ±S.D time interval between ingestion or
exposure and lavage was 1.95 ± 2.05 hours (range 0.5 -
10) in group I and in group II it was 2.5 ± 3.42 hours
(range 0.5 - 24). The mean ± S.D age in grou p I was 28.4
± 13.2 (range13 - 65) where is in group II was 27.6 ±
10.8 (range 12 - 68). The compounds ingested or acci-
dentally exposed to in two groups are shown in Table 1.
Table 1. Pesticides ingested or acc identally exposed to in 98
Pesticide consumed Group I Group II Total
Organophosphates 12 26 38
Aluminum phosphide14 19 33
Carbamates 4 0 4
Pyrethroids 2 2 4
Unknown 13 6 19
Total 45 53 98
U. B. Bhardwaj et al. / Health 3 (2011) 401-405
Copyright © 2011 SciRes. http://www.scirp.org/journal/HEALTH/Openly accessible at
In group I, mean volume of water or normal saline la-
vaged was 1108 mL (range 800 - 1500 mL). This could
not be known in group II. Hypoxemia i.e. SaO2 < 90%
was present before lavage in 11 (24.4%) patients where
as in group II, 23 (42.6%) had it at presentation (Table
2). In group I, significant drop in SaO2 (drop in SaO2 to
90% or lower) during lavage and post lavage was ob-
served in 6 and 2 patients respectively. (Tab le 3 ). In 5
patients post lavage SaO2 could not be known as they
died before lavage could be completed. All these patients
had severe aluminum phosphide poisoning.
The complications which occurred during or follow-
ing lavage are shown in Table 4. In group I, 44 patients
did not develop aspiration pneumonia (prophylactic en-
dotracheal intubation carried out in patients with GCS <
10). However, in one patient who had GCS of 3 and
prophylactic endotracheal intubation was not undertaken,
developed aspiration pneumonia (being defined as ap-
pearance of fresh patches of consolidation or increase in
patches as seen in post lavage chest x-ray. The other
complications observed in this group were sinus tachy-
cardia during lavage in 5 patients (11.1%), electrolyte
imbalance i.e. hyponatremia in one (2.2%), laryn-
gospasm in one (2.2%) and in one Ryle's tube got stuck
in throat (2.2%). In group II, 7 (13.2%) had aspiration
pneumonia. None of them had prophylactic endotracheal
Thirteen patients in group I and 18 in group II died. In
Table 2. Baseline BP, HR and SaO2 at admission in group I (45 patients) and group II (53 patients).
Systolic < 90* Systolic > 90* HR < 60** HR > 61 - 100**HR > 100**SaO2 < 90***SaO290-94*** SaO2 > 94***
Group No.# No. No. No. No. No. No. No.
I 7 38 1 2 9 15 11 12 22
II 18 35 1 29 23 23 8 22
*Blood Pres sure ( mm HG), **Heart rate/min, ***%O2 satur ation, # Number of patients.
Table 3. SaO2 pre, during lavage and post lavage in group I.
SaO2 SaO2 (admission) SaO2 (dur in g lavag e) SaO2 (post lavage)
< 90% 11 6 2
90% - 94% 12 3 4
> 94% 22 36 34
Total 45 45 40
Table 4. Complications related to gastric lavage in two groups.
Complication Group I (45) Group II (53) Fisher’s Exact test p
Aspiration pneumonia 1(2.2%) 7 (13.2%) 0.039*
Drop in SaO2 during lavage 6 (13.3%) -**
Laryngospasm 1 (2.2%) -**
Pneumothorax 0 0
Empyema 0 0
Tachycardia 1 (2.2%) -**
Ectopics/ST elevation 0 -**
Esophageal perforation 0 0
Gastric hemorrhage 0 -**
Electrolyte imbalance 1 (2.2%) -**
Conjunctival hemorrhage 0 0
Ryle’s tube stuck in throat 1 (2.2%) -**
U. B. Bhardwaj et al. / Health 3 (2011) 401-405
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none, death could be related to lavage associated com-
plications. The important cause of death in both groups
was severe aluminum phosphide poisoning.
Gastric lavage has to be carried out in all patients with
acute poisoning in India by treating physician irrespec-
tive of whether suicidal or accidental as lavage sample
has to be provided to legal authorities [1,2]. This is un-
like West where suicide is not considered a criminal of-
fence and it is not necessary to collect gastric lavage
sample. In West it has fallen out of favor having been
found ineffective [2-6]. and can lead to significant mor-
bidity and mortality [1,7] and in recent years, it is much
less carried out and if done at all is in either in a con-
senting or an unconscious intubated patient and is done
if poisoning is severe and patient comes very early.
However these studies on effectiveness of gastric lavage
have been carried out in well eq u ipped Western ho sp itals
in patients with drug overdoses wh ere effective antidotes
are available e.g. paracetamol and have low case fatality
ratio [4-6]. This is un like developing countries including
India where pesticide poisoning is the commonest [8-10].
These cases carry high mortality e.g. 70% with alumi-
num phosphide. The antidotes against pesticides either
do not exist or unavailable and unaffordable or partially
ineffective. Further, hospitals especially in rural areas
are poorly equipped. As the mortality is high and as
theoretically gastric lavage may offer some benefit, the
practice is common in developing countries [14,15].
Further in India, it is necessary to carry it out for medico
legal reasons [1,2].
In the present study, we tried to establish the safety of
gastric lavage using naso-gastric Ryle’s tube with small
aliquots of 100 - 200 mL of water or normal saline being
given till 1 - 1.5 liters were lavaged. A significant com-
plication observed was aspiration pneumonia (1/45 in
group I and 7/53 in group II) all these patients had not
undergone prophylactic endotracheal intubation when
patient was obtunded (GCS < 10). The higher incidence
of aspiration pneumonia in group II could also have been
due to lavage independent factors i.e. deep enin g of co ma
with time due to poison itself and transportation of pa-
tient with unprotected airway. However in none of
these patients it was severe and most of them, unless
they had ingested ALP survived (5/8 including one in
group I). The other complications in group I were sig-
nificant drop in oxygen during lavage (6/45) and post
lavage (2/40), tachycardia, electrolyte imbalance, laryn-
gospasm during lavage or post lavage was in very small
number of patients in group I (one each). We cannot say
about these in group II as we could not get any informa-
tion about these. None of the patients in both groups had
serious complications like gastric hemorrhage, gastric
perforation, empyema, ST elevation and conjunctival
These results are unlike those of Eddleston et al. from
SriLanka [8] where mainly orogastric tube was pre-
dominantly used with large volumes resulting in major
complications like severe aspiration, gastric perforation
and death. In north-west India where this tertiary centre
is located, in majority of peripheral hospitals usually
nasogastric Ryles tube is used for gastric lavage using
small aliquots and total small volume are being though
prophylactic intubation is uncommon due to both lack of
equipment and trained manpower. Though doctors and
nurses do carry lavage commonly at times it is also car-
ried out by non medical staff (unpublished data). This
observation however, cannot be extrapolated to hospitals
in other parts of India especially in rural areas where
Ryle’s tube is not always used and lavage is often being
carried out by untrained staff with no intubation being
carried out.
The study was not designed to know effectiveness of
gastric lavage in removing the pesticide and we cannot
comment on this. There is need to undertake studies to
find whether gastric lavage effectively removes pesti-
cides or not and if it is not effective why it should be
necessary to carry out lavage in all patients with acute
poisoning in India irrespective of nature, severity and
time interval and this will require Governmental action
in bringing about an amendment in IPC.
To conclude gastric lavage carried out with nasogas-
tric tube, using small aliquots of water or normal saline
with total lavage fluid less thn 2 L coupled with careful
prophylactic intubation in patients with pesticide poi-
soning is very safe. However, significant risk of aspira-
tion pneumonia remains if prophylactic intubation is not
carried out in patients with < GCS 10. Though aspiration
does occur if not intubated prphylactically, generally
aspiration pneumonia is not severe and doesn’t add to
mortality. A significant drop in SaO2 during lavage can
also occur.
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