Ryle's tube insertion is a commonly performed procedure in emergency departments, intensive care units, and operation theaters. The complications associated with RT include ulceration, bleeding, misplacement of the tube in airway, and clogging of the tube.1 Intragastric knotting is a rare complication of RT insertion.1

We report a case of a 40-year-old man with gastrointestinal stromal tumor posted for partial gastrectomy. The patient underwent a conventional general anesthesia technique and was intubated with a size 8 endotracheal tube as per protocol. A 16 F RT insertion was attempted postintubation. The RT was inserted by a blind technique and was advanced up to 50 mark as no resistance was felt during insertion. However, while checking the placement of the tube by whoosh test, resistance was felt during injection and the confirmatory sound was not heard in the epigastrium on auscultation. Hence, direct laryngoscopy was done to check for the position of the tube. No coils were found in the oropharynx during laryngoscopy and the tube was found to be entering the esophagus. However, the position could still not be confirmed by auscultation; hence, we decided to remove the tube. The proximal three-fourths of the RT could be removed without any problem, but resistance was felt toward the end. Hence, we pulled out the RT with greater force and the tube came out in toto without any trauma. On removal, a tight knot (Figs 1 and 2) was noted at the distal end of the RT.

Fig. 1

Knotted RT

Fig. 2

Tight knot at the distal end of RT


Although this phenomenon of knotting has been reported in the literature, its incidence appears low.1 Any difficulty during insertion or removal of a nasogastric tube should prompt immediate investigation to rule out possibility of knotting. When in doubt, a radiograph or an endoscopy can be performed to look for a knotted tube. The predisposing factors for knotting include narrow tube, multiple manipulations during insertion, deep insertion into stomach, and interference with endotracheal tube in an intubated patient.2,3 Knotting can result in respiratory distress, laryngeal and nasal trauma during removal attempts, and tracheoesophageal perforation.3,4 Knotting can be prevented by using larger diameter tubes and avoiding excess advancement into the stomach.

In our patient, the presence of an endotracheal tube was the only risk factor present. Though the insertion of the tube was smooth, on checking, we found resistance while injecting air. This indicated obstruction in the lumen of the tube and, hence, the tube had to be removed. The mistake that we did was that we pulled out the RT blindly through the nose despite having resistance. This might have tightened the knot all the more and could have traumatized the nasal mucosa and caused bleeding.5 Hence, it is a lesson that whenever there is resistance while pulling out the RT, it should not be done forcefully, but under laryngoscopic vision. If a knotted tube is found, it can be cut and the knotted portion removed orally under laryngoscopic vision.

Conflicts of interest

Source of support: Nil

Conflict of interest: None