Less is More: Nasogastric Tube Perforation in a Patient With Prior Roux-en-Y Gastric Bypass

Nasogastric (NG) tube placement is a routine inpatient procedure that is generally considered safe. NG perforation is a rare complication, but when it occurs, it is often serious or even deadly. The risk for perforation is increased in patients with a history of connective tissue disorders, inflammatory bowel disease, or prior abdominal surgeries such as Roux-en-Y gastric bypass (RYB). We present a fatal case of a 51-year-old woman with a recent RYB who suffered an NG-tube perforation leading to peritonitis and septic shock. This case highlights the extreme care healthcare providers must have when placing NG tubes in patients with prior abdominal surgeries, while offering suggestions on how to minimize the risk of fatal complications.