Gastroesophageal varices are among the most dangerous complications associated with cirrhosis. They are present in 50% to 60% of cirrhotic patients, and about 30% 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 are variceal size and the degree of liver dysfunction.1–3 While variceal bleeding stops spontaneously in 20% to 30% of cases, it recurs in 70% within 1 year of the initial episode.1–4 Mortality is as high as 50% 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 Somatostatin and its analogs cause splanchnic vasoconstriction leading to reduced portal pressure and portal blood flow while venodilators reduce portal pressure by reducing resistance to portal flow.7,8
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 and its therapeutic interventions. Removal of the balloon after its initial control of the bleeding results in a 50% rebleeding rate. It is also associated with serious complications such as esophageal ulceration and perforation.9 Emergency Physicians should become familiar with the SB and Minnesota tubes, as they can be potentially lifesaving in an emergent setting, especially when endoscopy is not available or contraindicated.
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).
The inflated balloons will control most bleeding. The esophageal balloon exerts lateral pressure to tamponade esophageal varices. The gastric balloon exerts pressure on the gastric cardia ...