Michael E. Winters and Edward A. Panacek

Introduction

Managing patients with acute gastrointestinal bleeding from gastroesophageal varices can be one of the most challenging scenarios in emergency medicine. These patients often have advanced liver disease and can arrive at the emergency department (ED) with massive hematemesis, airway compromise, hemodynamic instability, critical anemia, thrombocytopenia, and coagulopathy. Gastroesophageal varices are the fourth most common cause of upper gastrointestinal bleeding (UGIB) and account for almost 12% of cases (Fig. 41-1).¹ In patients with cirrhosis, varices account for up to 80% of cases of UGIB.^2,3 In patients with established gastric or esophageal varices, the annual incidence of acute hemorrhage ranges from 4% to 15%.^2,4

Over the past 3 decades, advances in resuscitation, critical care, pharmacology, and endoscopy have significantly reduced the mortality rate associated with acute variceal bleeding. In fact, mortality rates in patients with acute variceal bleeding currently range from 15% to 20%.1,5–7 Despite advances in management, a small number of patients with acute variceal bleeding fail standard therapy. Rescue therapies for this group of patients are limited and include balloon tamponade, surgery, and placement of a transjugular intrahepatic portosystemic shunt. This chapter details the indications and contraindications for balloon tamponade in patients with acute variceal bleeding, the techniques for placement of the various devices, and the potential complications of this intervention. Although this procedure is rarely needed and placement in the ED is not considered a standard intervention, emergency physicians with knowledge of the technique can attempt to place these critical and potentially lifesaving devices.

Background

In 1950, Sengstaken and Blakemore developed and described the use of a double-balloon device to control variceal hemorrhage.8,9 Since that time, the Sengstaken-Blakemore tube has become the most widely known balloon tamponade device. The Sengstaken-Blakemore tube has an esophageal and a gastric balloon, along with a gastric aspiration port that allows continuous suction of stomach contents (Fig. 41-2). In 1968, Edlich and colleagues, from the University of Minnesota, modified the Sengstaken-Blakemore tube by adding an esophageal aspiration port and increasing the capacity of the gastric balloon.¹⁰

Currently, three balloon tamponade devices are commercially available: the Linton-Nachlas, the Sengstaken-Blakemore, and the Minnesota tubes. In contrast to the Sengstaken-Blakemore and Minnesota tubes, the Linton-Nachlas tube is a single-balloon device that consists of a gastric balloon and two ports (esophageal and gastric) for aspiration and lavage. Because placement of these tubes remains a relatively rare procedure, most hospitals stock only one type of device. Regardless of the type of device, success rates for the control of hemorrhage with balloon tamponade tubes range from 60% to 90%.¹¹

Indications

The general management of unstable patients with acute variceal bleeding is described in detail elsewhere. In brief, initial resuscitation should focus on early endotracheal intubation; circulatory resuscitation, including blood transfusion and administration of vasoactive agents and antibiotics; and early endoscopy. Vasoactive agents should be given as soon as possible in cases of confirmed or suspected variceal hemorrhage. Vasoactive medications reduce portal pressure and have been shown to decrease or stop variceal bleeding.12–17 Somatostatin and its synthetic analogue octreotide decrease release of the vasodilator hormone glucagon, thereby indirectly resulting in splanchnic vasoconstriction and reduced portal blood flow. Vasopressin and its synthetic analogue terlipressin are direct vasoconstrictors and can be given systemically or locally during angiography. These two medications, however, can cause significant coronary, cerebral, and splanchnic ischemia and are typically used in patients who fail somatostatin or octreotide therapy.

Endoscopy by a gastroenterologist remains the “gold standard” for the diagnosis and treatment of acute variceal hemorrhage.² Sclerotherapy and band ligation are the two endoscopic techniques used to control bleeding esophageal or gastric varices. Endoscopic band ligation has been shown to be superior to sclerotherapy in initially controlling hemorrhage and improving survival.¹⁸ In fact, endoscopic band ligation is considered the treatment of choice for esophageal varices.^2,18,19

Balloon tamponade is indicated in unstable patients with massive hemorrhage in whom endoscopy either cannot be performed or is unsuccessful in controlling the bleeding. Balloon tamponade is also indicated when consultant physicians are unavailable and pharmacologic therapy with vasoactive agents has failed to stop the bleeding. In cases in which consultants are unavailable, balloon tamponade can be used to stabilize a patient for transfer to another institution with the resources to continue care.

It is important to recognize that balloon tamponade is only a temporizing measure. Even though success rates in controlling the initial hemorrhage are high, up to 50% of patients rebleed when the device is deflated.²⁰ Although rebleeding rates can be reduced with the concomitant use of vasoactive agents, arrangements must be made for more definitive control of varices in patients with a balloon tamponade device in place.

Contraindications

Because gastroesophageal balloon tamponade devices are typically placed as a final attempt to control hemorrhage and prevent imminent death, contraindications to the device are few. They are limited primarily to conditions that predispose patients to esophageal rupture with balloon inflation and include a history of esophageal stricture and recent esophageal or gastric surgery.

Procedure

Patients with an acute variceal hemorrhage that requires a balloon tamponade device are critically ill. Because these patients are at high risk for vomiting, aspiration, and airway compromise, endotracheal intubation should be strongly considered in all patients before placement of a balloon tamponade tube.²¹ For the rare patient who is not intubated, use of soft restraints and administration of appropriate analgesia and sedation are critical for a successful procedure.

For placement of a balloon tamponade tube, begin by testing the esophageal and gastric balloons for air leaks (Fig. 41-3, step 1). If there is any concern about a leak, submerge the balloons in water during inflation. If time permits, inflate the gastric balloon in 100-mL increments to the maximal recommended volume while measuring the pressure. Importantly, do not exceed a pressure of 15 mm Hg within the gastric balloon with each successive instillation of 100 mL. Note the pressure at full inflation of the gastric balloon. If no air leaks are detected, fully deflate the esophageal and gastric balloons and clamp the inflation ports. If the kit comes with plastic plugs, they may be used in lieu of clamps to occlude the ports and maintain deflation of the balloon during insertion (see Fig. 41-3, step 2). Once fully deflated, coat the balloons with a thin layer of water-soluble lubricating jelly.

When using the Sengstaken-Blakemore tube, it is important to recall that the device does not have an esophageal aspiration port. To construct a makeshift aspiration port, secure a nasogastric tube (NGT) to the tamponade tube with silk sutures such that the distal tip of the NGT is placed approximately 3 cm proximal to the esophageal balloon (see Fig. 41-3, step 3).

Position the patient properly for insertion of the tube, with the head of the bed elevated to at least 45 degrees. For patients who are unable to tolerate this position, use the left lateral decubitus position. For nonintubated patients, anesthetize the nasopharynx and oropharynx adequately. Accomplish this by using a topical anesthetic spray or jelly combined with a nebulized lidocaine solution.

Orogastric passage of the tamponade tube is the preferred route of insertion, especially in intubated patients. Nasogastric insertion can be attempted in nonintubated patients. Pass the tube at least to the 50-cm mark and preferably to the maximum depth allowed by the length of the tube (see Fig. 41-3, step 4). After the tube is inserted, apply continuous suction to its gastric and esophageal aspiration ports (see Fig. 41-3, step 5). Inflate the gastric balloon with approximately 50 mL of air and obtain a chest radiograph to confirm that the gastric balloon is below the diaphragm (Fig. 41-4; also see Fig. 41-3, step 6). Confirm the location of the gastric balloon, which is essential to reduce the risk for esophageal rupture from inflation of a misplaced gastric balloon.

Once the location of the gastric balloon is confirmed, connect a manometer to the pressure-monitoring outlet of the gastric balloon (see Fig. 41-3, step 7). Inflate the gastric balloon to the recommended total volume of air in 100-mL increments. Compare the pressure at each 100-mL increment with the values obtained during testing of the gastric balloon. If the pressure during inflation is more than 15 mm Hg higher than the testing pressure at an equivalent volume, it is likely that the gastric balloon has migrated to the esophagus. At this point deflate the gastric balloon and advance it further into the stomach. Obtain another chest radiograph before reinflation.

When the gastric balloon is fully inflated, clamp the inflation and pressure-monitoring ports (see Fig. 41-3, step 8). Slowly pull the device back until resistance is encountered (see Fig. 41-3, step 9). Resistance indicates that the gastric balloon has engaged the cardia and fundus of the stomach (Fig. 41-5). To maintain proper position of the gastric balloon, apply continuous traction. Accomplish this by using an overhead frame and pulley system, a football helmet or catcher’s mask, or the sponge rubber cuff (provided in most kits) for patients who underwent nasogastric insertion. Of these methods, the pulley system is preferred to deliver the recommended 0.5 to 1.0 kg of traction. If the emergency physician does not have the weights required for a pulley system, a 1-L bag of crystalloid solution conveniently provides 1 kg of traction (Fig. 41-6).

After traction is applied, connect the esophageal and gastric aspiration ports to continuous suction (see Fig. 41-3, step 10). If blood is obtained from either port, inflate the esophageal balloon to approximately 35 to 40 mm Hg. Similar to the gastric balloon, monitor inflation of the esophageal balloon with a manometer connected to the esophageal pressure–monitoring outlet (see Fig. 41-3, step 11). In general, do not inflate the esophageal balloon to more than 45 mm Hg. Keep esophageal balloon pressure at the lowest inflation pressure that achieves hemostasis. Occasionally, esophageal pressure may transiently spike to values approaching 70 mm Hg. This can occur with respiratory variation or esophageal contraction and is not indicative of overinflation. Once hemostasis is achieved, clamp the esophageal inflation port to prevent air leaks (Fig. 41-3, step 12).

If blood continues to be obtained from the gastric aspiration port despite maximal inflation of the esophageal balloon, it is usually indicative of an uncontrolled gastric varix. In this case, increase the traction gradually to a maximum of 1.2 kg.

Aftercare

Although the primary objective is to control variceal bleeding, the emergency physician must continue care of the patient with a balloon tamponade device until transfer to an intensive care unit, an operating room, a radiology suite, or another facility. Patients should be maintained in a position with the head of the bed elevated to approximately 45 degrees. In addition, continued administration of sedative and analgesic medication is critical. Connect the esophageal and gastric aspiration ports to continuous suction for approximately the first 12 hours.

Mucosal ulceration from direct pressure of the balloons can occur within just a few hours after tube placement. Accordingly, examine the tube, nares, mouth, tongue, and lips frequently, along with periodic monitoring of esophageal balloon pressure. Once the bleeding has been controlled for several hours, decrease the pressure in the esophageal balloon by approximately 5 mm Hg every 3 hours until a pressure of 25 mm Hg is reached. Regardless of the pressure, periodic deflation of the esophageal balloon for several minutes every 5 to 6 hours can decrease the incidence of mucosal ischemia and necrosis. Once hemorrhage is controlled and the patient is stabilized, balloon tamponade devices are generally left in place for approximately 24 hours.

Complications

Complications from balloon tamponade can be severe and occur in up to 14% of patients.²⁰ Major complications include airway obstruction, esophageal rupture, and aspiration pneumonitis. Airway obstruction can be catastrophic and usually results from migration of a dislodged esophageal balloon into the oropharynx.^10,22 Prevent proximal migration of the tube by maintaining adequate inflation of the gastric balloon, radiographic confirmation, and periodic monitoring of inflation pressure. Treat respiratory distress in nonintubated patients with a balloon tamponade device as airway obstruction until proved otherwise. In these patients use surgical scissors to cut across the lumen of the tube just distal to the inflation and aspiration ports. This will result in deflation of both balloons and allow immediate extraction of the device. Given the risk for airway obstruction, always keep surgical scissors at the bedside of patients who have a balloon tamponade device in place.

Esophageal perforation is another catastrophic complication of balloon tamponade that is almost universally fatal. This dreaded complication can occur from a misplaced gastric balloon, an overinflated esophageal balloon, or prolonged inflation of the esophageal balloon and result in decreased mucosal blood flow, ischemia, and necrosis. To minimize the risk for esophageal perforation, obtain radiographic confirmation of gastric balloon placement before full inflation. In addition, keep the esophageal balloon at the minimum pressure necessary to control hemorrhage. If the device is required for longer than 24 hours, periodically deflate the esophageal balloon to limit mucosal damage and decrease the risk for necrosis.

Aspiration pneumonitis can result from the aspiration of blood, oral secretions, and gastric contents and is a frequent complication of balloon tamponade.²³ The incidence of pneumonitis can be decreased by evacuating the stomach and intubating the patient before placement of the tamponade device.²¹

Additional complications of balloon tamponade include pain; ulceration of the lips, mouth, tongue, and nares; and esophageal and gastric mucosal erosions.²³ As discussed, patients with a tamponade device should receive adequate analgesia and sedation. Frequent monitoring of tube placement and pressure can decrease the incidence of esophageal or gastric mucosal erosions.

Conclusion

Balloon tamponade is a critical, lifesaving procedure that may be required in the ED management of unstable patients with bleeding gastroesophageal varices. Indications for placement of a balloon tamponade tube include unsuccessful control of hemorrhage with endoscopy and vasoactive medications, unavailability of consultant physicians when bleeding cannot be controlled with vasoactive therapy, and massive hemorrhage preventing endoscopy. Although complications of balloon tamponade can be fatal, their incidence can be markedly reduced through a stepwise approach to tube placement. Once bleeding is controlled, the emergency physician must continue to monitor tube position and measure balloon pressure until the patient is transferred from the ED.

References