II. Indications

  1. Esophageal Varices with Exsanguination
    1. Stabilize until emergent endoscopy

III. Precautions

  1. Emergent endoscopy is preferred if immediately available
  2. Gastrointestinal Balloon Tamponade is a high risk procedure

IV. Contraindications

  1. Esophageal Stricture
  2. Recent esophageal or gastric surgery

V. Mechanism

  1. Balloons inflated within Stomach and esophagus
    1. Applies direct pressure on bleeding Varices
    2. Applies pressure to left gastric vein (supplies the esophageal venous plexus)

VI. Types

  1. Minnesota tube
  2. Linton Tube
  3. Sengstaken-Blakemore Tube
    1. Four proximal ports
      1. Gastric and esophageal balloon ports
      2. Gastric esophageal port (central at proximal end)
      3. Esophageal aspiration port (2-3 cm below the level of the other ports, along the tube)
    2. Long esophageal balloon
    3. Short Stomach balloon
    4. Nasogastric Tube type distal ports for gastric aspiration

VII. Technique: Sengstaken-Blakemore Tube Technique

  1. Preparation
    1. Gown and glove with full personal protectection equipment
  2. Endotracheal Intubation
    1. Secure airway before placement
    2. Endotracheal Tube prevents aspiration as well as accidental balloon insertion into airway
  3. Device
    1. Test balloons for air leaks prior to insertion
  4. Insertion
    1. Insert balloon device in same manner as a Nasogastric Tube and feed to the 50 cm mark
    2. Apply continuous suction to gastric port and esophageal port
  5. Gastric balloon
    1. Inject air into balloon while auscultating over Stomach
    2. Insert 50 cc air into gastric port
  6. Confirm positioning on XRay
    1. Gastric balloon must be in Stomach (not esophagus), otherwise risks Esophageal Rupture
  7. Further inflate gastric balloon
    1. Attach manometer using Y-Tube, and check pressure at every 100 cc of inflation
    2. Inflate gastric balloon to 250 cc by inserting another 200 cc
    3. Balloon filled with Contrast Media and water to allow for confirmation of tube position
    4. Marked increase in pressure may indicate tube displacement
  8. Secure Gastric Tube closure
    1. Apply clamp, red Rubber tubing or tape to gastric port (not hemostats)
  9. Apply traction to tube
    1. Apply counter-balance with the weight of IV fluid bag
  10. Secure the tube
    1. Use an Endotracheal Tube holder
  11. Evaluate for further bleeding
    1. Suction ports
    2. Inflate esophageal balloon to 30 mmHg (using manometer and Y-adapter) if bleeding persists
    3. May further inflate balloon to 45 mmHg if bleeding still persists
  12. Monitor for tube dislodgement
    1. Immediately cut tube to decompress

VIII. Imaging

  1. Confirm tube placement with xray or Bedside Ultrasound
  2. Serial position checks are required to confirm gastric balloon remains in Stomach

IX. Efficacy

  1. Successful for stabilization in >60% of cases

X. Complications

  1. Inability to control bleeding (resulting in death)
  2. Respiratory obstruction
  3. Aspiration Pneumonitis (if placed in non-intubated patient)
  4. Mucosal injuries (ulcerations of oral, esophageal or gastric mucosa)
  5. Tracheal rupture
  6. Duodenal rupture
  7. Esophageal Rupture

XI. References

  1. Sampson (2016) Crit Dec Emerg Med 30(4): 14-5
  2. Spangler, Swadron, Mason and Herbert (2016) EM:Rap C3, p. 8

Images: Related links to external sites (from Bing)

Related Studies

Ontology: Esophagogastric tamponade with balloon (C0192395)

Concepts Therapeutic or Preventive Procedure (T061)
SnomedCT 38436007
CPT 43460
English Esophagogastric tamponade, with balloon (Sengstaken type), ESOPG/GSTR TAMPONADE W/BALO SENGSTAKEN TYPE, Esophagogastric tamponade using balloon, Esophagogastric tamponade with balloon, Oesophagogastric tamponade with balloon, Esophagogastric tamponade with balloon (procedure), PRESSURE TREATMENT ESOPHAGUS, Pressure treatment esophagus
Spanish taponamiento esofagogástrico con balón (procedimiento), taponamiento esofagogástrico con balón

Ontology: Balloon tamponade of esophagus (C0473009)

Concepts Therapeutic or Preventive Procedure (T061)
SnomedCT 173679008
English Balln tamponade oesoph varices, Balloon tamponade esophagus, Balloon tamponade oesophagus, Balloon tamponade of esophageal varices, Balloon tamponade of esophagus, Balloon tamponade of oesophageal varices, Balloon tamponade of oesophagus, Balloon tamponade of esophagus (procedure)
Spanish taponaje con balón de várices esofágicas (procedimiento), taponaje con balón de várices esofágicas, taponaje esofágico con balón

Ontology: Sengstaken-Blakemore tube (C1283123)

Concepts Medical Device (T074)
SnomedCT 360088001
English Sengstaken-Blakemore tube, sengstaken-blakemore tube, sengstaken blakemore tube, Sengstaken-Blakemore tube (physical object)
Spanish sonda de Sengstaken-Blakemore (objeto físico), sonda de Sengstaken-Blakemore, tubo de Sengstaken-Blakemore

Ontology: Minnesota tube (C1283124)

Concepts Medical Device (T074)
SnomedCT 360089009
English minnesota tube, Minnesota tube (physical object), Minnesota tube
Spanish sonda de Minnesota (objeto físico), sonda de Minnesota, tubo de Minnesota