Chapter 63. Balloon Tamponade of Gastrointestinal Bleeding

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 to tamponade varices. When both are inflated, they meet to compress the gastric cardia against the diaphragm and block the upward flow of collateral blood from feeding the esophageal varices.

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

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 hemorrhage has terminated based upon nasogastric lavage and aspiration.

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.

• SB tube (or Minnesota tube)
• Topical anesthetic spray
• Tongue blades
• Lidocaine or water-soluble jelly
• 60 mL syringe
• Catheter tips for the syringe
• Two wall-suction setups with plastic connectors and suction tubing
• Adhesive tape
• Rubber shod clamps, hemostats, or plugs
• Scissors
• Y-adapter or three-way stopcock
• Intravenous extension tubing
• Pressure bulb
• Mercury manometer or handheld manometer
• Bite block
• Nasogastric tube
• Football helmet, catcher's mask, or endotracheal tube holder

The SB tube is a triple-lumen and double-balloon system (Figures 63-1 & 63-2). It is available in a variety of sizes, including pediatric sizes. The proximal end contains three ports. A syringe attaches to the esophageal balloon inflation port to inflate the esophageal balloon. A syringe attaches to the gastric balloon inflation port to inflate the gastric balloon. The gastric aspiration port may be used to aspirate gastric contents, instill fluid into the stomach, or lavage the stomach. The ports may be opened and closed by the application of rubber shod clamps, hemostats, or plugs. The tube is made of a soft rubber and is extremely flexible. The proximal or esophageal balloon is elongated. The distal or gastric balloon is round. The maximum volume to inflate each balloon is manufacturer- and size-specific. Numerous perforations in the distal end of the tube allow for gastric aspiration and lavage.

The Minnesota tube is a quadruple-lumen and double-balloon system (Figure 63-3). It is similar to the SB tube with the exception of an additional port and lumen. The esophageal aspiration port allows saliva and esophageal secretions to be aspirated from a perforation just above the esophageal balloon. The only advantage of this tube over the SB tube is that the SB tube requires a nasogastric tube to be passed nasally or orally into the esophagus to aspirate secretions.

Explain the risks and benefits of the procedure to the patient and/or their representative. An informed consent should be obtained for the procedure. Thoroughly assess the patient's airway and breathing. Have a low threshold to protect the airway by endotracheal intubation. Endotracheal intubation is required before performing the procedure if the patient has altered mental status, airway compromise, or the potential for airway compromise. Patients are often ill and require intubation anyway. The procedure and the tube are not well tolerated, and intubation makes it easier. Endotracheal intubation reduces the risk of aspiration.

The patient should have intravenous access established with at least two large-bore catheters. Cardiac monitoring, continuous pulse oximetry, and supplemental oxygen should be applied. The patient may require the judicious use of intravenous sedatives and soft restraints during the insertion and inflation of the tube. The patient should be resuscitated, including blood transfusion, to stabilize them hemodynamically.

Place the patient sitting upright to semi-upright by elevating the head of the bed at least 45°. This is the ideal position. The procedure can be performed with the patient in the left lateral decubitus position if they cannot sit upright. The procedure can be performed with the patient supine if they are is endotracheally intubated.

Apply topical anesthetic spray to the nostrils and pharynx. Insert a nasogastric tube or an Ewald tube. Aspirate the stomach contents. Evacuate the stomach with tap-water lavage through the nasogastric tube (or Ewald tube), then remove the nasogastric tube.

Prepare the equipment. Flush the aspiration ports with air to ensure their patency. Inflate the balloons with the maximum recommended volume of air and check for leaks. It is advisable to inflate the balloons under water to look for small leaks. Connect the mercury manometer to the balloon ports and inflate the balloons to the recommended pressures and check for leaks. Completely deflate the balloons. Record the manometric pressure of each balloon when it is deflated. Insert the plastic plugs in the balloon inflation ports or loosely clamp each port with a hemostat or rubber shod clamp.10–12 Lubricate the SB tube with a water-soluble lubricant. Place the SB tube on a table. Position a nasogastric tube next to the SB tube so that the tip of the nasogastric tube is just above the esophageal balloon (Figure 63-4). Place a piece of tape on both tubes to mark a common point, proximal to the 50 cm mark of the SB tube, that will be outside of the patient. The nasogastric tube will be inserted after the SB tube is placed. Alternatively, position the tubes as above and tape both tubes together at two or three sites. This allows the nasogastric tube to be inserted simultaneously with the SB tube.

The SB tube may be inserted through the nose or through the mouth. The nasal route is more difficult to use and may be associated with a higher rate of complications. Despite this, many physicians recommend this route in the awake patient. The oral route is the preferred route of insertion by some physicians, especially if the patient is intubated. Apply topical anesthetic spray into the nasal cavity and oropharynx if the SB tube will be placed nasogastrically. Apply topical anesthetic spray into the oropharynx if the SB tube will be placed orally. Place a bite block in the patient's mouth if the SB tube will be placed orally to prevent the patient from biting the SB tube.

Insert the lubricated SB tube until the 50 cm mark is located just outside the nares, or outside the teeth if inserted through the mouth. Flush the gastric aspiration port with air while auscultating over the epigastrium (Figure 63-5). A rush of air should be heard to ensure that the distal end of the SB tube is properly positioned within the stomach. If possible, confirm the position of the SB tube with portable plain radiographs or fluoroscopy. It is imperative to know that the gastric balloon is within the stomach before it is inflated. Apply suction to the gastric aspiration port.

Remove the rubber shod clamp and plastic plug from the gastric balloon inflation port. Connect the Y-adapter with a handheld or mercury manometer and a pressure bulb or a 50 mL syringe with a catheter tip to the gastric balloon inflation port (Figure 63-6). Measure the intragastric balloon pressure. If the intragastric balloon pressure after intubation is 15 mmHg greater than that prior to the intubation, deflate the balloon, as it may be located within the esophagus. Inflate the gastric balloon in increments with 50 to 100 mL boluses of air (Figure 63-7). Deflate the balloon immediately if the patient experiences chest pain. This signifies that the gastric balloon is in the esophagus. Clamp the gastric balloon inflation port when the gastric balloon is inflated initially with 200 to 250 mL of air. Gently pull the SB tube back until resistance is felt as the gastric balloon lodges against the gastroesophageal junction (Figure 63-8).

Apply slight tension to the SB tube to occlude the veins at the gastroesophageal junction. This tension must be maintained by one of several methods. Fix the upper end of the SB tube as it exits from the mouth or nose to the crossbar of a football helmet or a catcher's mask (Figure 63-9). Apply over-the-bed traction with a one pound weight. Alternatively, fix the upper end of the SB tube, if it emerges from the nostril, by a cuff of sponge rubber held in place by an adhesive tape band. Insert the nasogastric tube until the tape is at the level of the tape on the SB tube (Figure 63-10).

Connect the gastric aspiration port and the nasogastric tube to the suction source (Figure 63-11). Place the gastric aspiration port and the nasogastric tube on low intermittent suction. Unclamp the esophageal balloon port clamp. Attach the Y tubing, manometer, and pressure bulb (or 50 mL syringe) to the esophageal balloon port (Figure 63-11). Inflate the esophageal balloon to a pressure of 25 mmHg if bleeding continues through the gastric aspiration port or the nasogastric tube. If bleeding continues to persist, increase the esophageal balloon pressure in 5 mmHg increments until 45 mmHg is achieved or the bleeding stops. Double clamp the SB tube to prevent accidental deflation of the balloons. If bleeding continues despite maintaining the esophageal balloon pressure at 45 mmHg, this is suggestive of a gastric wall varix. In this case, check that the tube is snugged up on the nose firmly and taped securely. Finally, fill the gastric balloon with more air gradually up to a total volume of 300 mL of air.

The above technique is also applicable to the four-lumen esophagogastric tamponade (Minnesota) tube. This tube is a modification of the triple-lumen SB tube that incorporates a separate esophageal suction port to the existing gastric suction port.13,14 The design of the Minnesota tube may help prevent aspiration of esophageal contents.15 Always check the manufacturer characteristics regarding the maximum inflation volume of both the gastric and esophageal balloons, as these are dependent upon the tube manufacturers.

Recently proposed is an effective methodology for placement of the SB tube endoscopically.16 This method will avoid the need to obtain radiologic confirmation of the gastric balloon within the stomach.16 Delay in treatment while waiting for a radiologic confirmation may put patients at risk, as they are almost always in critical condition and require immediate attention.4–6 If endoscopic intervention is not successful, pass an SB tube and confirm the position of the gastric balloon under direct visualization through the endoscope. The balloons are inflated and secured in the usual fashion.16

Check the pressure in the balloons periodically with the mercury manometer or keep the manometer attached for constant monitoring. Obtain a portable radiograph to confirm proper placement of the SB tube and the inflated balloons. The patient may be reclined, but always maintain at least 6 to 10 in. of head elevation on the bed to prevent aspiration in the awake patient. Tape a scissors to the head of the bed for quick access in case the balloon requires emergent deflation (Figure 63-12).

If the bleeding is controlled, reduce the esophageal balloon pressure by 5 mmHg every 3 hours until 25 mmHg is reached without bleeding from the nasogastric tube in the esophagus or the gastric aspiration port. Deflate the esophageal balloon for 5 minutes every 6 hours to avoid esophageal pressure necrosis. Give the patient nothing by mouth. Oral medications, if required, may be administered through the gastric aspiration port. Check the tension on the SB tube every 3 hours and adjust it as necessary. Verify patency of the SB and nasogastric tubes by checking the gastric and esophageal return regularly and periodically flushing both lumens.

Monitor the patient continuously for signs of chest pain, respiratory distress, and aspiration. Migration of the esophageal balloon into the hypopharynx of an awake patient will result in respiratory distress. This situation is a true emergency and the tube should be removed immediately. Cut the SB tube between the ports and the patient with a scissors (Figure 63-12). The balloons will immediately deflate and allow the removal of the SB tube.

The esophageal balloon should not remain inflated for more than 24 hours to avoid mucosal necrosis. The SB tube is usually left in place with the gastric or gastric and esophageal balloons inflated for 24 hours if variceal bleeding is controlled. If there is no bleeding after 24 hours, deflate the esophageal balloon and leave the gastric balloon inflated for an additional 24 hours. The SB tube may be left in place for an additional 24 hours after both balloons are deflated. If variceal hemorrhage recurs, the appropriate balloons should be reinflated while alternative therapy to control bleeding is sought. Patients who rebleed have a higher mortality rate. Therefore, other therapeutic interventions—such as rubber banding, sclerotherapy, transjugular intrahepatic portocaval shunt, or surgery—should be considered. Remove the SB tube if hemostasis persists for 24 hours after deflation of both balloons. Control of esophageal variceal bleeding can be achieved by balloon tamponade in 50% to 94% of patients.18–22 However, rebleeding occurs in 38%.

Major complications occur in up to 15% of patients and lethal complications have been described in up to 6.5% of patients.18–22 Complications associated with the SB tube are often life-threatening. The airway may become occluded due to proximal migration of the esophageal balloon into the hypopharynx of the awake patient from traction on the SB tube.17 The patient will begin choking and gagging if not intubated. Cut the SB tube distal to the ports to immediately deflate the balloons and allow the SB tube to be removed. Pulmonary aspiration, and subsequent pneumonia, may occur during SB tube insertion. Airway protection by endotracheal intubation should be considered in all patients prior to insertion of the SB tube.18

Despite endotracheal intubation, the SB tube may still become malpositioned and end up in the airway.27 Inflation of the balloons in the airway can result in respiratory distress, respiratory tract obstruction, tracheal or bronchial rupture, or tracheoesophageal fistulas from pressure necrosis. This is why it is essential to confirm proper placement prior to inflating the balloons.

Excessive balloon pressure or prolonged balloon inflation may lead to pressure necrosis and ulcerations of the esophagus, gastroesophageal junction, and/or stomach. Periodic deflation of the esophageal balloon every 6 hours will help prevent this. Rupture or lacerations of the esophagus, stomach, or small intestine may occur.19 Esophageal rupture can result in mediastinitis, abscess formation, and sepsis. These can be prevented by adhering to proper balloon inflation techniques with pressure monitoring. Cardiac arrhythmias and pulmonary edema can occur and require continuous monitoring in the setting of an intensive care unit. Pulmonary edema is often due to pressure from the esophageal balloon on mediastinal structures.

Numerous other complications are associated with the use of the SB or Minnesota tube. Unintentional deflation of the balloons can be prevented by the application of rubber shod clamps or hemostats to the balloon inflation ports after the balloons are inflated. Cut the SB tube distal to the ports if the balloons will not deflate. The patient may become agitated from the discomfort of the tube, migration of the tube into the hypopharynx resulting in hypoxemia and asphyxiation, or as chest and back pain is experienced from a misplaced or overdistended balloon. Hiccoughs are due to pressure on the diaphragm by the balloons. Excessive traction on the tube can result in epistaxis or pressure necrosis of the lips, nose, or tongue. Use air and not a liquid to inflate the balloons. Liquid in the balloons causes them to be heavy, increases the risk of pressure necrosis, and makes them hard to deflate.

Balloon tamponade of variceal bleeding is an uncommonly performed procedure in the Emergency Department. The SB tube plays an important role in the temporary control of hemorrhage from esophageal or gastric varices.20–22 It is used in cases of variceal bleeding, usually documented by endoscopy, that continues despite aggressive medical management including lavage, correction of blood clotting abnormalities, intravenous somatostatin or vasopressin infusion, rubber banding, and emergent sclerotherapy.16,23–25 The SB tube can also be placed if these methods are contraindicated or unavailable. Despite the initial success of balloon tamponade in the control of variceal hemorrhage, sustained control of bleeding occurs in only 40% to 50% of patients.26 Balloon tamponade has been shown to be as effective as intravenous vasopressin in controlling esophageal variceal bleeding. Only 25% of patients with ascites, jaundice, and encephalopathy achieve lasting hemostasis with balloon tamponade. Long-term efficacy in terms of rebleeding depends in part on the patient's underlying liver disease.16 Maintain a low threshold to intubate the patient endotracheally in order to prevent aspiration, protect the airway, and prevent airway occlusion from migration of the esophageal balloon.