There are numerous relative contraindications to balloon tamponade of variceal bleeding. The procedure should not be performed if the equipment required is defective or missing components. Untrained support staff make the procedure, as well as the aftercare, more difficult. Significant active medical problems (e.g., respiratory failure, congestive heart failure, and cardiac arrhythmias) preclude the use of balloon devices. Incomplete gastric lavage leaving particulates in the stomach can cause retching and elevated intraabdominal pressure. The balloons will not properly position and may perforate the esophagus if the patient has a hiatal hernia. Esophageal ulcerations preclude the use of the esophageal balloon (a gastric balloon may be used). The device is not helpful if a variceal source of bleeding cannot be demonstrated by examination, history, and/or nasogastric aspiration. Patients with altered mental status, confusion, diminished gag reflexes, hypoxemia, or who are uncooperative should have their airway secured by endotracheal intubation prior to this procedure. Recurrent bleeding after the initial successful tamponade should be followed by endoscopic or operative intervention.