Esophageal Balloon Tamponade

Aka: Esophageal Balloon Tamponade, Sengstaken-Blakemore Tube, Linton Tube, Minnesota tube, Blakemore Tube, Esophagogastric Balloon Tamponade, Gastrointestinal Balloon Tamponade, GI Balloon Tamponade

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II. Indications

  1. Esophageal Varices with Exsanguination and hemodynamic instability
    1. Stabilize until emergent endoscopy for definitive care (e.g. variceal banding, sclerotherapy, TIPS)
    2. Adjunct to maximal medical therapy (e.g. Blood Transfusion, Antibiotics, vasoactive agents)

III. Precautions

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

IV. Contraindications

  1. Hemodynamically stable patient
  2. Unsecured airway
    1. Place Endotracheal Tube first
  3. Other relative 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. Linton Tube (Linton-Nachlas Tube, LNT)
    1. Three proximal ports
      1. Gastric balloon port
      2. Gastric suction port
      3. Esophageal suction port
    2. Balloons
      1. Single, Long and large Gastric Balloon (600 ml)
      2. Contrast with 2 balloons on the MT and SBT tubes
  2. Minnesota tube (MT)
    1. Four proximal ports
      1. Gastric balloon port
      2. Esophageal balloon port
      3. Gastric suction port
      4. Esophageal suction port
    2. Balloons
      1. Large Gastric Balloon (500 ml)
      2. Long Esophageal Balloon (30 to 45 ml)
  3. Sengstaken-Blakemore Tube (SBT)
    1. Three proximal ports
      1. Gastric and esophageal balloon ports (2)
      2. Gastric aspiration/suction port
        1. Nasogastric Tube type distal ports for gastric aspiration
    2. Balloons
      1. Long esophageal balloon (30-45 mmHg)
      2. Short Stomach balloon (250 ml)

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
    2. Measure and mark the 50 cm position on the tube (or bridge of nose to xiphoid process)
  4. Insertion
    1. Position patient supine with head of bed at 45 degrees
    2. Lubricate the device
    3. Insert balloon device in same manner as a Nasogastric Tube and feed to the 50 cm mark
    4. Apply continuous suction to gastric port and esophageal port
  5. Gastric balloon
    1. Inject air into balloon while auscultating over Stomach
    2. Only insert 50 ml air into gastric port initially while awaiting xray confirmation of position
  6. Confirm positioning on Portable 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. Gastric balloon inflation prevents tube from migrating back into Esophagus
    5. 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 a 1 Liter IV fluid bag
    2. Use rolled gauze to attach the external tube end to the IV bag
      1. Tie rolled gauze to the external end of the tube
      2. Tie the other end of rolled gauze to the IV bag
  10. Secure the tube
    1. Use an Endotracheal Tube holder
    2. Note the tube position at the patient's teeth
  11. Evaluate for further bleeding
    1. Irrigate and Suction ports for blood (or use a separate Nasogastric Tube or Orogastric Tube)
    2. Inflate esophageal balloon to 25 to 30 mmHg (using manometer and Y-adapter) if bleeding persists
    3. May further inflate balloon to 40-45 mmHg if bleeding still persists
  12. Monitor for tube dislodgement
    1. Immediately cut tube to decompress if dislodged
    2. Tube may remain in place for up to 24 to 48 hours
    3. Continuous suction may be applied to the aspiration ports for first 12 hours
    4. Deflate the esophageal balloon every 6 hours for a few minutes each time to prevent Mucosal Ulceration

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% (range 30 to 90%) of cases

X. Complications

  1. Inability to control bleeding (resulting in death)
  2. Airway or 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. Ruiz-Betancourt and Welsh (2025) Crit Dec Emerg Med 39(2): 19-20
  2. Sampson (2016) Crit Dec Emerg Med 30(4): 14-5
  3. Spangler, Swadron, Mason and Herbert (2016) EM:Rap C3, p. 8
  4. Bridwell (2022) J Emerg Med 62(4): 545-8 +PMID: 35065859 [PubMed]

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