Nasogastric tubes are commonly used, not only in surgical practice but in a
ll disciplines. Their use, however, is not without complications. We presen
t the first reported case of duodenal obstruction due to a swallowed nasoga
stric tube, and recommend that nasogastric tubes be used in their entirety
(uncut) with the splayed distal end intact. This simple procedure will prev
ent a rare but distressing complication that might be amenable only to lapa
rotomy.