Baloon Tamponade of Gastroesophageal Varices

are limited and include surgery, placement of a transjugular
C H A P T E R 4 1 intrahepatic portosystemic shunt or a covered esophageal metal

stent, or balloon tamponade.8 This chapter details the indica-
tions and contraindications for balloon tamponade in patients
Balloon Tamponade of with acute variceal bleeding, the techniques for placement of
the various devices, and the potential complications of this
Gastroesophageal Varices intervention. Although this procedure is rarely needed and
placement in the ED is not considered a standard intervention,
Michael E. Winters
emergency physicians with knowledge of the technique can
attempt to place these critical and potentially lifesaving devices.
BACKGROUND
INTRODUCTION
In 1950, Sengstaken and Blakemore developed and described
Managing patients with acute gastrointestinal bleeding from the use of a double-balloon device to control variceal hemor-
gastroesophageal varices can be one of the most challenging rhage.9,10 Since that time, the Sengstaken-Blakemore tube (Video
scenarios in emergency medicine. These patients often have 41.1) has become the most widely known balloon tamponade
advanced liver disease and can arrive at the emergency depart- device. The Sengstaken-Blakemore tube has an esophageal
ment (ED) with massive hematemesis, airway compromise, and a gastric balloon, along with a gastric aspiration port that
hemodynamic instability, critical anemia, thrombocytopenia, allows continuous suction of stomach contents (Fig. 41.2). In
and coagulopathy. Gastroesophageal varices are the fourth most 1968, Edlich and colleagues, from the University of Minnesota,
common cause of upper gastrointestinal bleeding (UGIB) modified the Sengstaken-Blakemore tube by adding an esopha-
and account for almost 12% of cases (Fig. 41.1).1 In patients geal aspiration port and increasing the capacity of the gastric
with cirrhosis, varices account for up to 80% of cases of balloon.11
UGIB.2,3 In patients with established gastric or esophageal Currently, three balloon tamponade devices are commercially
varices, the annual incidence of acute hemorrhage ranges from available: the Linton-Nachlas, the Sengstaken-Blakemore, and
4% to 15%.2,4 the Minnesota tubes. In contrast to the Sengstaken-Blakemore
Over the past 3 decades, advances in resuscitation, critical and Minnesota tubes, the Linton-Nachlas tube is a single-
care, pharmacology, and endoscopy have significantly reduced balloon device that consists of a gastric balloon and two ports
the mortality rate associated with acute variceal bleeding. In (esophageal and gastric) for aspiration and lavage. Because
fact, mortality rates in patients with acute variceal bleeding placement of these tubes remains a relatively rare procedure,
currently range from 15% to 20%.1,5–7 Despite advances in most hospitals stock only one type of device. Regardless of
management, up to 20% of patients with acute variceal bleeding the type of device, success rates for the control of hemorrhage
fail standard therapy.8 Rescue therapies for this group of patients with balloon tamponade tubes range from 60% to 90%.12
Balloon Tamponade of GE Varices

Indications Equipment
Unstable patients with massive variceal bleeding in the
following scenarios:
Endoscopy is not available Viscous
60-mL syringe
Endoscopy is unsuccessful at controlling bleeding lidocaine
(catheter-tip)
Consultant physicians are unavailable and vasoactive Nasal
agents have failed to stop bleeding spray Manometer
Bulb inflator
Contraindications
History of esophageal stricture
Recent esophageal or gastric surgery
Sengstaken-
Complications Blakemore tube
Airway obstruction Tube
clamps
Esophageal rupture
Aspiration pneumonitis “Y” tube
Pain
Ulceration of lips, mouth, tongue, or nares
Esophageal and gastric mucosal erosions Scissors
Arrhythmia
Dislodgment of previous variceal bands
Review Box 41.1 Balloon tamponade of gastroesophageal varices: indications, contraindications, complications, and equipment.
852
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CHAPTER 41 Balloon Tamponade of Gastroesophageal Varices 853
A B
Figure 41.1 Endoscopic appearance of esophageal varices. A, Upper gastrointestinal endoscopy

demonstrating dilated and straight veins (small esophageal varices) in the distal end of the esophagus
(arrows). B, Upper gastrointestinal endoscopy demonstrating large esophageal varices, greater than
5 mm in diameter, with a fibrin plug (arrow) representing the site of recent bleeding. (From Feldman
M, Friedman LS, Brandt LJ, editors: Sleisinger and Fordtran’s gastrointestinal and liver disease, ed 9,
Philadelphia, 2010, Saunders.)
Gastric balloon
Distal Endoscopy by a gastroenterologist remains the “gold
inflation port Depth
markers suction standard” for the diagnosis and treatment of acute variceal
Gastric holes hemorrhage.2 Sclerotherapy and band ligation are the two
aspiration port
endoscopic techniques used to control bleeding esophageal or
gastric varices. Endoscopic band ligation has been shown to
Esophageal balloon
Esophageal be superior to sclerotherapy in initially controlling hemorrhage
inflation port Gastric balloon
balloon and improving survival.19 In fact, endoscopic band ligation is
(≤ 45 mm Hg air) (200–250 mL air) considered the treatment of choice for esophageal varices.2,19,20
Figure 41.2 The Sengstaken-Blakemore (SB) tube. Note that this Balloon tamponade is indicated in unstable patients with
tube does not have esophageal aspiration ports; a nasogastric tube massive hemorrhage in whom endoscopy either cannot be
must be attached to the SB tube to allow esophageal suctioning (see performed or is unsuccessful in controlling the bleeding. Balloon
text for details.) tamponade is also indicated when consultant physicians are
unavailable and pharmacologic therapy with vasoactive agents
has failed to stop the bleeding. In cases in which consultants
are unavailable, balloon tamponade can be used to stabilize a
INDICATIONS patient for transfer to another institution with the resources
to continue care.
The general management of unstable patients with acute variceal It is important to recognize that balloon tamponade is only
bleeding is described in detail elsewhere. In brief, initial a temporizing measure. Even though success rates in controlling
resuscitation should focus on early endotracheal intubation; the initial hemorrhage are high, up to 50% of patients rebleed
circulatory resuscitation, including blood transfusion and when the device is deflated.21 Although rebleeding rates can
administration of vasoactive agents and antibiotics; and, most be reduced with the concomitant use of vasoactive agents,
importantly, early endoscopy. Vasoactive agents should be given arrangements must be made for more definitive control of
as soon as possible in cases of confirmed or suspected variceal varices in patients with a balloon tamponade device in place.
hemorrhage. Vasoactive medications reduce portal pressure
and have been shown to decrease or stop variceal bleeding.13–18
Somatostatin and its synthetic analogue octreotide decrease CONTRAINDICATIONS
release of the vasodilator hormone glucagon, thereby indirectly
resulting in splanchnic vasoconstriction and reduced portal Because gastroesophageal balloon tamponade devices are
blood flow. Vasopressin and its synthetic analogue terlipressin typically placed as a final attempt to control hemorrhage and
are direct vasoconstrictors and can be given systemically or prevent imminent death, contraindications to the device are
locally during angiography. These two medications, however, few. They are limited primarily to conditions that predispose
can cause significant coronary, cerebral, and splanchnic ischemia patients to esophageal rupture with balloon inflation and include
and are typically used in patients who fail somatostatin or a history of esophageal stricture and recent esophageal or gastric
octreotide therapy. surgery.
854 SECTION VII Gastrointestinal Procedures
PROCEDURE include the avoidance of inadvertent tube placement in an

esophageal diverticulum, dislodgment of previously placed
Patients with an acute variceal hemorrhage that requires a variceal bands, and inflation of the gastric balloon in a hiatal
balloon tamponade device are critically ill. Because these patients hernia. This approach may be feasible if the emergency provider
are at high risk for vomiting, aspiration, and airway compromise, has experience with the endoscope device.
endotracheal intubation should be strongly considered in all Once the location of the gastric balloon is confirmed, connect
patients before placement of a balloon tamponade tube.22 For a manometer to the pressure-monitoring outlet of the gastric
the rare patient who is not intubated, use of soft restraints and balloon (see Fig. 41.3, step 7). Inflate the gastric balloon to
administration of appropriate analgesia and sedation are critical the recommended total volume of air in 100-mL increments.
for a successful procedure. Compare the pressure at each 100-mL increment with the
For placement of a balloon tamponade tube, begin by testing values obtained during testing of the gastric balloon. If the
the esophageal and gastric balloons for air leaks (Fig. 41.3, pressure during inflation is more than 15 mm Hg higher than
step 1). If there is any concern about a leak, submerge the the testing pressure at an equivalent volume, it is likely that
balloons in water during inflation. If time permits, inflate the the gastric balloon has migrated to the esophagus. At this
gastric balloon in 100-mL increments to the maximal recom- point deflate the gastric balloon and advance it further into the
mended volume while measuring the pressure. Importantly, stomach. Obtain another chest radiograph before reinflation.
do not exceed a pressure of 15 mm Hg within the gastric When the gastric balloon is fully inflated, clamp the inflation
balloon with each successive instillation of 100 mL. Note the and pressure-monitoring ports (see Fig. 41.3, step 8). Slowly
pressure at full inflation of the gastric balloon. If no air leaks pull the device back until resistance is encountered (see Fig.
are detected, fully deflate the esophageal and gastric balloons 41.3, step 9). Resistance indicates that the gastric balloon has
and clamp the inflation ports. If the kit comes with plastic engaged the cardia and fundus of the stomach (Fig. 41.5). To
plugs, they may be used in lieu of clamps to occlude the ports maintain proper position of the gastric balloon, apply continuous
and maintain deflation of the balloon during insertion (see traction. To accomplish this, use an overhead frame and pulley
Fig. 41.3, step 2). Once fully deflated, coat the balloons with system, a football helmet or catcher’s mask, or the sponge
a thin layer of water-soluble lubricating jelly. rubber cuff (provided in most kits) for patients who underwent
When using the Sengstaken-Blakemore tube, it is important nasogastric insertion. Of these methods, the pulley system is
to recall that the device does not have an esophageal aspira- preferred to deliver the recommended 0.5 to 1.0 kg of traction.
tion port. To construct a makeshift aspiration port, secure a If the emergency physician does not have the weights required
nasogastric (NG) tube to the tamponade tube with silk sutures for a pulley system, a 1-L bag of crystalloid solution can
such that the distal tip of the NG tube is placed approximately conveniently provide 1 kg of traction (Fig. 41.6).
3 cm proximal to the esophageal balloon (see Fig. 41.3, After traction is applied, connect the esophageal and gastric
step 3). aspiration ports to continuous suction (see Fig. 41.3, step 10).
Patients should be as heavily sedated as allowed by cardio- If blood is obtained from either port, inflate the esophageal
vascular parameters. Patients are often hypotensive, limiting balloon to approximately 35 to 40 mm Hg. Similar to the
the use of many agents. Ketamine would be an excellent choice gastric balloon, monitor inflation of the esophageal balloon
for sedation of most patients. Position the patient properly with a manometer connected to the esophageal pressure-
for insertion of the tube, with the head of the bed elevated to monitoring outlet (see Fig. 41.3, step 11). In general, do not
at least 45 degrees. For patients who are unable to tolerate inflate the esophageal balloon to more than 45 mm Hg. Keep
this position, use the left lateral decubitus position. For the esophageal balloon pressure at the lowest inflation pressure
nonintubated patients, anesthetize the nasopharynx and oro- that achieves hemostasis. Occasionally, esophageal pressure
pharynx adequately. Accomplish this by using a topical anesthetic may transiently spike to values approaching 70 mm Hg. This
spray or jelly combined with a nebulized lidocaine solution. can occur with respiratory variation or esophageal contraction
Orogastric passage of the tamponade tube is the preferred and is not indicative of overinflation. Once hemostasis is
route of insertion, especially in intubated patients. Nasogastric achieved, clamp the esophageal inflation port to prevent air
insertion can be attempted in nonintubated patients. Pass the leaks (see Fig. 41.3, step 12).
tube at least to the 50-cm mark and preferably to the maximum If blood continues to be obtained from the gastric aspiration
depth allowed by the length of the tube (see Fig. 41.3, step 4). port despite maximal inflation of the esophageal balloon, it
A 2015 case series reported the successful use of indirect usually indicates an uncontrolled gastric varix. In this case,
laryngoscopy to rapidly guide the tamponade tube into the increase the traction gradually to a maximum of 1.2 kg.
esophagus.23 After the tube is inserted, apply continuous suction
to its gastric and esophageal aspiration ports (see Fig. 41.3,
step 5). Inflate the gastric balloon with approximately 50 mL AFTERCARE
of air and obtain a chest radiograph to confirm that the gastric
balloon is below the diaphragm (Fig. 41.4; also see Fig. 41.3, Although the primary objective is to control variceal bleeding,
step 6). Confirm the location of the gastric balloon; this is the emergency physician must continue care of the patient
essential to reduce the risk for esophageal rupture from inflation with a balloon tamponade device until transfer to an intensive
of a misplaced gastric balloon. care unit, an operating room, a radiology suite, or another
Case reports have described the use of an endoscope to facility. Patients should be maintained in a position with the
guide placement of the tamponade tube.24,25 Essentially, a snare head of the bed elevated to approximately 45 degrees. In
is placed through the endoscope and used to grasp the end of addition, it is critical to continue administering sedative and
the tamponade tube. Use of the endoscope allows direct analgesic medications. Connect the esophageal and gastric
visualization of the tamponade tube and confirmation that the aspiration ports to continuous suction for approximately the
gastric balloon is in the stomach. Added benefits to this approach first 12 hours.
Balloon Tamponade of Gastroesophageal Varices
1 2
Tube
clamp
Plastic
Deflate plug
Test the esophageal and gastric balloons for air leaks, by sub- Fully deflate the esophageal and gastric balloons. Clamp the
merging under water during inflation. If time permits, record inflation ports with a tube clamp, or insert the plastic plugs
pressures during gastric balloon inflation (see text for details). supplied with the tube into the tube lumen. Lubricate the tube
and balloons with water-soluble jelly.
3 4
SB tube
Silk sutures
NG tube 3 cm
Deflated
esophageal
balloon
Construct a makeshift esophageal aspiration port by securing a Pass the tube orally (preferred) or nasally, to at least the 50-cm
standard NG tube to the SB tube with silk sutures. The distal tip mark, or to the maximum depth allowed by the tube.
of the NG tube should be 3 cm proximal to the esophageal
balloon.
5 6 Inflate 50 mL of air
Gastric inflation
port
Suction
After the tube is fully inserted, apply continuous suction to the Inflate the gastric balloon with 50 mL of air and obtain a chest
gastric and esophageal aspiration ports. radiograph to confirm the position of the gastric balloon below
the diaphragm.
Figure 41.3 Balloon tamponade of gastroesophageal varices with the Sengstaken-Blakemore (SB)
tube. NG, Nasogastric.
Continued
7 Manometer
8
Gastric
port
Y-tube
connector
Connect a manometer to the gastric inflation port via the Y-tube. When the gastric balloon is fully inflated, clamp the gastric inflation
Inflate the gastric balloon to the recommended total volume in port. Note that bare metal hemostats should not be used, as they
100-mL increments. Compare pressure at each 100-mL increment may damage the tube. Cover the clamping surfaces with cut pieces
to values obtained during testing. High pressures suggest the of red rubber tubing or tape (arrow).
gastric balloon has migrated into the esophagus. (See text for
details).
9 10
Esophageal suction
(via attached NG tube)
Upward
traction
Gastric suction
(via gastric port)
Slowly pull back the device until resistance is encountered. Apply After traction is applied, continuously suction the gastric
continuous traction to the tube. (See text and Fig. 41.6). aspiration port and the attached NG tube which is in the
esophagus. If blood is obtained from either source, then
esophageal balloon inflation is required.
11 Bulb 12
Recommended
inflator maximum 45 mm Hg
Esophageal
port
Y-tube
Inflate the esophageal balloon using the same configuration as in Once hemostasis is achieved, clamp the esophageal inflation
step 7. In general, do not inflate the balloon > 45 mm Hg (see text). port to prevent air leaks.
The use of a bulb inflator is helpful for this step.
Figure 41.3, cont’d
Mucosal ulceration from direct pressure of the balloons decrease the pressure in the esophageal balloon by approximately
can occur within just a few hours after tube placement. Accord- 5 mm Hg every 3 hours until a pressure of 25 mm Hg is
ingly, examine the tube, nares, mouth, tongue, and lips fre- reached. Regardless of the pressure, periodically deflate the
quently, and monitor esophageal balloon pressure periodically. esophageal balloon for several minutes every 5 to 6 hours to
Once the bleeding has been controlled for several hours, decrease the incidence of mucosal ischemia and necrosis. Once
A
Hanging
IV pole
Figure 41.4 Chest radiograph showing a fully inflated gastric balloon

(arrow) of a Sengstaken-Blakemore tube properly positioned under the
diaphragm and in the stomach. Before inflation, obtain a radiograph
to confirm that the gastric balloon is indeed in the stomach. Inflation
of the gastric balloon in the esophagus can lead to esophageal rupture. Kerlix
(Courtesy Dr. Frank Gaillard, http://www.radiopaedia.org.) 1-L bag
of IV fluid
Traction
Sengstaken-
Blakemore tube
B
Figure 41.6 To maintain proper position of the gastric balloon and

tamponade on the gastric fundus, apply continuous traction to the
A B C D tube. Traditional methods of applying traction include the use of an
overhead frame and pulley system, a football helmet, or a catcher’s mask.
Figure 41.5 The Sengstaken-Blakemore tube in position. A, With A simpler solution uses a roll of Kerlix (Medtronic, Minneapolis, MN)
both balloons deflated. B, After partial inflation of the gastric tube to and a bag of intravenous (IV) fluid. A, Make a lark’s head knot around
confirm proper position. C, After full inflation of the gastric balloon the proximal portion of the tube with the Kerlix. B, Tie the end of
with appropriate traction applied to engage the cardia and fundus of the the Kerlix to a 1-L bag of IV fluid and suspend it from an overhead
stomach. D, After full inflation of the gastric and esophageal balloons. IV pole. The liter bag of fluid will provide the appropriate 1 kg of
traction. Most patients require sedation to tolerate this procedure.
hemorrhage is controlled and the patient is stabilized, balloon

tamponade devices are generally left in place for approximately
24 hours. device, treat respiratory distress as airway obstruction until
proved otherwise. In these patients, use surgical scissors to cut
across the lumen of the tube just distal to the inflation and
COMPLICATIONS aspiration ports. This will result in deflation of both balloons
and allow immediate extraction of the device. Given the risk
This is a difficult procedure that is rarely performed; hence, for airway obstruction, always keep surgical scissors at the
complications from balloon tamponade can be severe and occur bedside of patients who have a balloon tamponade device
in up to 20% of patients.21,25 Major complications include airway in place.
obstruction, esophageal rupture, and aspiration pneumonitis. Esophageal perforation is another catastrophic complication
Airway obstruction can be catastrophic and usually results of balloon tamponade that is almost universally fatal. This
from migration of a dislodged esophageal balloon into the dreaded complication can occur from a misplaced gastric
oropharynx.11,26 Prevent proximal migration of the tube by balloon, an overinflated esophageal balloon, or prolonged
maintaining adequate inflation of the gastric balloon, radio- inflation of the esophageal balloon and can result in decreased
graphic confirmation, and periodic monitoring of inflation mucosal blood flow, ischemia, and necrosis. To minimize the
pressure. In nonintubated patients with a balloon tamponade risk for esophageal perforation, obtain radiographic confirmation
of gastric balloon placement before full inflation. In addition, CONCLUSION

keep the esophageal balloon at the minimum pressure necessary
to control hemorrhage. If the device is required for longer Balloon tamponade is a critical, lifesaving procedure that may
than 24 hours, periodically deflate the esophageal balloon to be required in the ED management of unstable patients with
limit mucosal damage and decrease the risk for necrosis. bleeding gastroesophageal varices. Indications for placement
Aspiration pneumonitis can result from the aspiration of of a balloon tamponade tube include unsuccessful control of
blood, oral secretions, and gastric contents and is a frequent hemorrhage with endoscopy and vasoactive medications,
complication of balloon tamponade.27 The incidence of unavailability of consultant physicians when bleeding cannot
pneumonitis can be decreased by evacuating the stomach and be controlled with vasoactive therapy, and massive hemorrhage
intubating the patient before placement of the tamponade preventing endoscopy. Although complications of balloon
device.22 tamponade can be fatal, their incidence can be markedly reduced
Additional complications of balloon tamponade include pain; through a stepwise approach to tube placement. Once bleeding
ulceration of the lips, mouth, tongue, and nares; and esophageal is controlled, the emergency physician must continue to monitor
and gastric mucosal erosions.27 As discussed, patients with a tube position and measure balloon pressure until the patient
tamponade device should receive adequate analgesia and seda- is transferred out of the ED.
tion. Frequent monitoring of tube placement and pressure
can decrease the incidence of esophageal or gastric mucosal
REFERENCES ARE AVAILABLE AT www.expertconsult.com
erosions.
CHAPTER 41 Balloon Tamponade of Gastroesophageal Varices 858.e1
REFERENCES 14. Planas R, Quer JC, Boix J, et al: A prospective randomized trial comparing
somatostatin and sclerotherapy in the treatment of acute variceal bleeding.
1. Peura DA, Lanza FL, Gostout CJ, et al: The American College of Hepatology 20:370–375, 1994.
Gastroenterology Bleeding Registry: preliminary findings. Am J Gastroenterol 15. Sung JJ, Chung SC, Lai CW, et al: Octreotide infusion or emergency
92:924–928, 1997. sclerotherapy for variceal haemorrhage. Lancet 342:637–641, 1993.
2. Cardenas A: Management of acute variceal bleeding: emphasis on endoscopic 16. Levacher S, Letoumelin P, Pateron D, et al: Early administration of terlipres-
therapy. Clin Liver Dis 14:251–262, 2010. sin plus glyceryl trinitrate to control active upper gastrointestinal bleeding
3. D’Amico G, De Franchis R: Upper digestive bleeding in cirrhosis: post- in cirrhotic patients. Lancet 346:865–868, 1995.
therapeutic outcome and prognostic indicators. Hepatology 38:599–612, 17. Ioannou G, Doust J, Rockey DC: Terlipressin for acute esophageal variceal
2003. hemorrhage. Cochrane Database Syst Rev (1):CD002147, 2003.
4. de Franchis R, Primignani M: Natural history of portal hypertension in 18. Escorsell A, Ruiz del Arbol L, Planas R, et al: Multicenter randomized
patients with cirrhosis. Clin Liver Dis 5:645–663, 2001. controlled trial of terlipressin versus sclerotherapy in the treatment of
5. Chalasani N, Kahi C, Francois F, et al: Improved patient survival after acute variceal bleeding: the TEST study. Hepatology 32:471–476, 2000.
acute variceal bleeding: a multicenter, cohort study. Am J Gastroenterol 19. Laine L, el-Newihi HM, Migikovsky B, et al: Endoscopic ligation compared
98:653–659, 2003. with sclerotherapy for the treatment of bleeding esophageal varices. Ann
6. Carbonell N, Pauwels A, Serfaty L, et al: Improved survival after variceal Intern Med 119:1–7, 1993.
bleeding in patients with cirrhosis over the past two decades. Hepatology 20. Garcia-Tsao G, Sanyal AJ, Grace ND, et al: Prevention and management
40:652–659, 2004. of gastroesophageal varices and variceal hemorrhage in cirrhosis. Hepatology
7. Bambha K, Kim WR, Pedersen R, et al: Predictors of early re-bleeding 46:922–938, 2007.
and mortality after acute variceal haemorrhage in patients with cirrhosis. 21. Haddock G, Garden OJ, McKee RF, et al: Esophageal tamponade in
Gut 57:814–820, 2008. the management of acute variceal hemorrhage. Dig Dis Sci 34:913–918,
8. Escorsell A, Pavel O, Cardenas A, et al: Esophageal balloon tamponade 1989.
versus esophageal stent in controlling acute refractory variceal bleeding: 22. Mandelstam P, Zeppa R: Endotracheal intubation should precede esopha-
a multicenter randomized, controlled trial. Hepatology 63:1957–1967, 2015. gogastric balloon tamponade for control of variceal bleeding. J Clin
9. Westphal K: Uber eine Kompressionsbehandlung der Blutungen aus Gastroenterol 5:493–494, 1983.
Osophagusvarizen. Dtsch Med Wochenschr 56:1135, 1930. 23. Schlichting AB, Gardner-Gray JM, Hurst G: Novel use of Glidescope
10. Sengstaken RW, Blakemore AH: Balloon tamponage for the control of indirect laryngoscopy for insertion of a Minnesota tube for variceal bleeding.
hemorrhage from esophageal varices. Ann Surg 131:781–789, 1950. J Emerg Med 49:40–42, 2015.
11. Edlich RF, Lande AJ, Goodale RL, et al: Prevention of aspiration pneumonia 24. Thomson A: Safe and efficacious placement of Sengstaken-Blakemore
by continuous esophageal aspiration during esophagogastric tamponade tubes. Gastrointest Endosc 70:401, 2009.
and gastric cooling. Surgery 64:405–408, 1968. 25. Negi S: Inserting the Sengstaken-Blakemore tube successfully in a difficult
12. Feneyrou B, Hanana J, Daures JP, et al: Initial control of bleeding from case of uncontrollable esophageal variceal bleeding, using sutures and an
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82 patients. Am J Surg 155:509–511, 1988. 26. Butler ML: Variceal hemorrhage: a review. Mil Med 145:766–770, 1980.
13. Gotzsche PC, Gjorup I, Bonnen H, et al: Somatostatin v placebo in bleeding 27. Panes J, Teres J, Bosch J, et al: Efficacy of balloon tamponade in treatment
oesophageal varices: randomised trial and meta-analysis. BMJ 310:1495– of bleeding gastric and esophageal varices: results in 151 consecutive
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are limited and include surgery, placement of a transjugular

C H A P T E R 4 1 intrahepatic portosystemic shunt or a covered esophageal metal

Balloon Tamponade of GE Varices

Figure 41.1 Endoscopic appearance of esophageal varices. A, Upper gastrointestinal endoscopy

PROCEDURE include the avoidance of inadvertent tube placement in an

Balloon Tamponade of Gastroesophageal Varices

Figure 41.3, cont’d

Figure 41.4 Chest radiograph showing a fully inflated gastric balloon

Figure 41.6 To maintain proper position of the gastric balloon and

hemorrhage is controlled and the patient is stabilized, balloon

of gastric balloon placement before full inflation. In addition, CONCLUSION

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