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Gastroesophageal varices are among the most dangerous complications associated with cirrhosis. They are present in 50 to 60 percent of cirrhotic patients, and about 30 percent of them will experience an episode of variceal hemorrhage within 2 years of the diagnosis of varices.1 The major factors that determine the risk of bleeding in cirrhotics are variceal size and the degree of liver dysfunction.1–3 While variceal bleeding stops spontaneously in 20 to 30 percent of cases, it recurs in 70 percent within 1 year of the initial episode.1–4 Mortality is as high as 50 percent in the first year.5 Variceal bleeding accounts for almost one-third of deaths in cirrhotic patients. Variceal hemorrhage has a poor prognosis if it is associated with coexisting or subsequent complications including rebleeding, infection, hepatic dysfunction, and portal pressure ≥ 12 mmHg.6–7 Splanchnic vasoconstrictors can reduce portal pressure by reducing portal venous inflow, while venodilators reduce portal pressure by reducing resistance to portal flow.7,8

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Doctors Sengstaken and Blakemore developed the concept of balloon tamponade to control bleeding esophageal and gastric varices in 1950. They developed a triple-lumen and double-balloon system that bears their names. The Sengstaken-Blakemore (SB) tube is used as a temporizing measure to stop variceal bleeding until more definitive means are available. A variant of the SB tube is the Minnesota tube. It is a quadruple-lumen, double-balloon system. These tubes are rarely used today due to the significant complications and the widespread availability of endoscopy. Emergency Physicians should become familiar with the SB and Minnesota tubes, as they can be potentially lifesaving in an emergent setting.

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Cirrhosis results in portal venous hypertension and a decrease in blood flow through the portal system. Collateral circulation develops, so that the blood in the portal vein can find an alternative route to the inferior vena cava. Large collateral systems include the esophageal, gastric, paraumbilical, and rectal veins. The left gastric and esophageal veins form one of the larger collateral circulation channels due to the pressure generated from the portal venous system and the large volume of blood flow through them. The collateral veins distend from the pressure and large volume of blood flow, resulting in weakening of the walls of the vein. Ulceration and rupture of these veins can result in large amounts of blood entering the esophagus and stomach. Patients may present with bright red blood per rectum, hematemesis, hemorrhagic shock, hypotension, or complications associated with hypotension and hemorrhage (e.g., cerebrovascular accidents and myocardial infarction).

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Balloon tamponade should be considered in patients with acute bleeding from esophageal and/or gastric varices if medical therapy (e.g., somatostatin, octreotide, vasopressin) or emergent endoscopic therapy (banding or sclerotherapy) is not available, contraindicated, or unsuccessful.

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Absolute contraindications to balloon tamponade of variceal bleeding include a history of esophageal stricture, a history of recent surgery involving the gastroesophageal junction, or if the bleeding has terminated based upon nasogastric lavage and ...

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