Knotted nasogastric tube: a rare, overlooked yet preventable complication.

Nasogastric tubes (NGTs) have long been used for various indications, most commonly to decompress the stomach of its contents in intestinal obstruction or after abdominal surgery, to provide enteral feeding or to allow enteral liquid medication administration. Recently greater importance has been given to the correct placement NGTs to avoid serious complications. We present a case of a spontaneously knotted NGT that was identified and safely removed without complications, but which may have resulted from suboptimal placement. We discuss this case to raise awareness of this complication and how to minimize the likelihood of it happening and improve patient outcome.