Key messages

• Balloon tamponade is a lifesaving procedure in patients with torrential variceal hemorrhage.

• It is a procedure which should be undertaken by skilled personnel, and the patient should be nursed in an intensive care or high-dependency environment by experienced staff.

• Tamponade, although highly efficacious in obtaining hemostasis, has a complication rate of up to 20 per cent and can carry a mortality if complicated by aspiration pneumonia, sepsis, and multiple organ failure or by esophageal rupture.

Variceal hemorrhage is a frequent and potentially life-threatening complication in patients with portal hypertension. It has a mortality of approximately 30 per cent, related to the complications of hypovolemia, multiple organ failure, and decompensation of liver disease. Prognosis of the bleeding episode is determined by the magnitude of blood loss and degree of liver failure, with a mortality of approximately 70 per cent for those in Childs-Pugh stage C and 15 per cent in those in Childs-Pugh stage A.

Acute variceal hemorrhage is a medical emergency that should be managed in an intensive care or high-dependency environment by an experienced multidisciplinary team working to well-understood protocols. The aim of therapy should be to correct hypovolemia and achieve hemostasis at the bleeding site. All patients require large-bore venous access, central venous catheter insertion, and appropriate colloid infusion. Coagulation factors, fresh frozen plasma, and platelet transfusions are also likely to be required. Altered conscious level should be acted upon to prevent aspiration, and such patients will frequently benefit from early elective intubation and ventilation. Therapies should be directed to controlling hemorrhage; pharmacological therapy to decrease portal inflow with somatostatin analogs is frequently advocated, and the patient should undergo endoscopy by an experienced practioner with skills in the management of acute variceal hemorrhage. If such an individual is not available and/or if there is massive exsanguinating hemorrhage, balloon tamponade should be considered. This controls hemorrhage by compression of the varices within the stomach and limiting inflow of blood into the esophageal varices by compression just below the gastroesophageal junction.

Tamponade is a highly effective form of therapy, controlling hemorrhage in 85 to 95 per cent of cases in experienced centers, but carries several potential drawbacks. These include the risk of aspiration and pulmonary sepsis, mucosal damage due to direct compression, and incorrect placement with the risk of esophageal rupture. In view of the latter, the tube should ideally only be inflated for 24 h prior to removal and endoscopic therapy or further definitive therapy in the form of surgical shunt or a transjugular intrahepatic portosystemic stent shunt (TIPSS) procedure. Very few patients will safely tolerate a Sengstaken tube; the majority, and certainly all those who are encephalopathic, require intubation to protect their airway and allow safe management of the tube.

Prior to inserting the tube it is essential that the operator is aware of the type of balloon tamponade system being inserted (e.g. a Sengstaken-Blackmore three- or four-lumen tube, a Minnesota tube, or a Linton tube). The practioner should be aware of which lumens are for aspiration and which are for inflation, and furthermore the volumes required to inflate the gastric balloon. Guidelines are listed in Table.!, but these are for guidance only. It should always be ensured that the volumes are appropriate for the system used.

Table 1 Guidelines for volume and pressure requirements in balloon tamponade

The balloons should be test inflated prior to insertion; they should then be evacuated and plugs should be inserted into the pressure-monitoring balloon. In normal circumstances it is almost never necessary to inflate the esophageal balloon to obtain hemostasis provided that the gastric balloon has been appropriately inserted and distended. The end of the tube should be lubricated and passed either nasally or orally to the posterior pharyngeal wall and then down the esophagus and into the stomach. The gastric balloon is then inflated with an appropriate volume of sterile water and Omnipaque (in order to facilitate visualization on the chest radiograph). It is essential that the operator is certain that the tube has been passed into the stomach prior to inflating the gastric balloon. Firm traction is then applied to the tube until resistance is felt and the balloon is firm against the diaphragm. Aspiration is commenced on both the gastric aspiration lumen, in order to keep the stomach clear of blood, and on the esophageal aspiration port to decrease the risk of aspiration. The tube is then fixed in position either with a tube fixation system or by attaching it to the patient's skin using a dressing such as Elastoplast or Sleek.

The traction should be checked every 2 to 4 h and the skin fixation system moved from right to left on a regular basis to prevent pressure damage to the skin. It is not advisable to apply traction to the tube by the method of attaching a 1-kg weight, such as a bag of intravenous fluid, to the tube. There are two reasons for this: the amount of traction applied may be excessive, and it is also highly variable, changing whenever the patient moves and thus potentially resulting in excessive or subtherapeutic amounts of traction on the gastroesophageal junction.

If the tube is correctly placed, hemostasis is almost always achieved. If bleeding continues consideration should be given to misplacement of the tube, inadequate insufflation of the gastric balloon, and incorrect application of traction on the gastroesophageal junction. In addition, the possibility that another lesion is accounting for the bleeding or that there are gastric varices in a position that does not allow for compression with the gastric balloon should be considered. As mentioned above, it is rarely necessary to inflate the esophageal balloon but, if this is required, it should be inflated with air, the pressure should be maintained at an appropriate level (25-40 mmHg), and it should be deflated intermittently. It should probably never be inflated except after review by experienced staff. After 24 h or earlier, the gastric balloon should be deflated (the amount in the balloon should be documented clearly in the patient's notes) and the tube gently removed immediately prior to endoscopic review.

In summary, balloon tamponade is highly efficacious in controlling life-threatening bleeding from gastric and esophageal varices, but it should be recognized that it is a specialist technique that carries a complication rate of up to 20 per cent. Although this can be limited by appropriate medical and nursing care of patients requiring balloon tamponade, complications can still occur. If there is any concern that the gastric balloon has been inflated in the esophagus or the gastroesophageal junction has been damaged, the balloons should be deflated immediately. It is then essential not to undertake endoscopy, but to perform appropriate imaging to define the problem and transfer the patient to a unit allowing both cardiothoracic and hepatobiliary support to facilitate repair of the esophagus and surgical shunt to control the portal hypertension. Figure ! shows an appropriately placed Sengstaken-Blackmore tube. Figure.2 shows an incorrectly placed tube with the gastric balloon filled with air, and Fig 3 shows the subsequent Gastrografin study confirming a significant lower esophageal tear.

Fig. 1 Appropriately placed Sengstaken-Blackmore tube.
Fig. 2 Incorrectly placed Sengstaken-Blackmore tube.

Fig. 3 Gastrografin study showing a lower esophageal tear caused by incorrect tube placement.

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