Esophageal Balloon Tamponade

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Last modified 22/04/2025

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W16 Esophageal Balloon Tamponade

Howard R. Doyle

image Before Procedure

Indications

• Failure to achieve hemostasis after endoscopic treatment of bleeding esophageal varices
• As a temporizing measure when endoscopic treatment is not immediately available or emergency transcutaneous intrahepatic portosystemic shunt is being arranged

Contraindications

• Known or suspected esophageal tear

Equipment

• Minnesota tube

image Procedure

• If not already done, proceed with endotracheal intubation for airway protection.
• Test the integrity of the gastric and esophageal balloons of the Minnesota tube by inflating them fully. Deflate the balloons, making sure all the air is out.
• Insert tube transnasally, and advance it into the esophagus its full length. If the transnasal route cannot be used, transoral insertion is also acceptable.
• Put 30 to 50 mL of air through the gastric port, clamp it, and check for correct placement. The partially inflated gastric balloon must be clearly seen below the diaphragm on a chest x-ray. Do not overinflate the gastric balloon during this step, as accidental full balloon inflation in the esophagus would likely lead to esophageal rupture.
• Once placement is confirmed, inflate gastric balloon fully (500-700 mL).
• Pull the tube back slowly until meeting with resistance. Traction can then be applied in a number of ways: with an overhead frame-pulley system—such as the one used for skeletal traction—or by securely taping the tube to the nose. More creatively, the patient can be fit with a football helmet or a catcher’s mask, which are then used to stabilize the tube. The frame-pulley system has the advantage that the degree of traction can be accurately measured. A 1-kg weight is enough (a 1-L bag of a crystalloid solution can be conveniently used).
• Separately connect the gastric and esophageal ports to suction, and monitor the output. If blood continues to come out of the esophageal port, inflate the esophageal balloon to 25 to 35 mm Hg (this is best done by attaching a three-way stopcock to the inflation port, with one of the limbs connected to a transducer for continuous pressure monitoring).

image After Procedure

Postprocedure Care

• If inflated, monitor the pressure of the esophageal balloon at least once a day, but preferably continuously.
• Monitor the angle of the tube with respect to the nose, and adjust accordingly to prevent pressure necrosis.
• The tube should be removed as early as possible. However, it is not known how long a tube can safely remain in place.
• To remove the tube, the steps are reversed. First deflate the esophageal balloon, keeping the gastric balloon on traction. If bleeding does not resume, one can proceed to discontinue the traction while keeping the gastric balloon fully inflated. Finally, the gastric balloon is deflated, and the tube is removed.

Complications

• Common:

• Esophageal and fundal ulcerations
• Pressure necrosis of the alae nasae

• Infrequent:

• Aspiration pneumonia

• Serious, rare complications:

• Esophageal rupture
• Airway obstruction

image Outcomes and Evidence

• Primary hemostasis can probably be achieved in about 90% of cases.
• The evidence is weak because most studies are at least 2 decades old, employed different types of tubes (e.g., Sengstaken-Blakemore, Linton, or Minnesota), and few were randomized. This situation is unlikely to change, as balloon tamponade is seldom needed nowadays.

Suggested Reading

Sengstaken R, Blakemore A. Balloon tamponade for the control of hemorrhage from esophageal varices. Ann Surg. 1950;131:781-789.

Conn H. Hazards attending the use of esophageal tamponade. N Engl J Med. 1958;259:701-707.

Hermann RE, Traul D. Experience with the Sengstaken-Blakemore tube for bleeding esophageal varices. Surg Gynecol Obstet. 1970;130:879-885.

Pitcher JL. Safety and effectiveness of the modified Sengstaken-Blakemore tube: A prospective study. Gastroenterology. 1971;61:291-298.

Johansen T, Baden H. Reappraisal of the Sengstaken-Blakemore balloon tamponade for bleeding esophageal varices: Results in 91 patients. Scand J Gastroenterol. 1973;8:181-183.

Bauer JL, Kreel I, Kark AE. The use of the Sengstaken-Blakemore tube for immediate control of bleeding esophageal varices. Ann Surg. 1974;179:273-277.

Novis BH, Duys P, Barbezat GO, et al. Fibreoptic endoscopy and the use of the Sengstaken tube in acute gastrointestinal hemorrhage in patients with portal hypertension and varices. Gut. 1976;17:258-263.

Terés J, Cecilia A, Bordas JM, et al. Esophageal tamponade for bleeding varices: Controlled trial between the Sengstaken-Blakemore tube and the Linton-Nachlas tube. Gastroenterology. 1978;75:566-569.

Chojkier M, Conn HO. Esophageal tamponade in the treatment of bleeding varices: A decadal progress report. Dig Dis Sci. 1980;25:267-272.

Terblanche J, Yakoob HI, Bornman PC, et al. A five-year prospective evaluation of tamponade and sclerotherapy. Ann Surg. 1981;194:521-530.

Hunt PS, Korman MG, Hansky J, Parkin WG. An 8-year prospective experience with balloon tamponade in emergency control of bleeding esophageal varices. Dig Dis Sci. 1982;27:413-416.

Sarin SK, Nundy S. Balloon tamponade in the management of bleeding oesophageal varices. Ann R Coll Surg Engl. 1984;66:30-32.

Prindiville T, Trudeau W. A comparison of immediate versus delayed endoscopic injection sclerosis of bleeding esophageal varices. Gastrointest Endosc. 1986;32:385-388.

Moretó M, Zaballa M, Bernal A, et al. A randomized trial of tamponade or sclerotherapy as immediate treatment for bleeding esophageal varices. Surg Gynecol Obstet. 1988;167:331-334.

Feneyrou B, Hanana J, Daures JP, Prioton JB. Initial control of bleeding from esophageal varices with the Sengstaken-Blakemore tube. Am J Surg. 1988;155:509-511.

Panés J, Terés J, Bosch J, Rodés J. Efficacy of balloon tamponade in treatment of bleeding gastric and esophageal varices: Results in 151 consecutive episodes. Dig Dis Sci. 1988;33:454-459.

Haddock G, Garden OJ, McKee RF, Anderson JR, Carter DC. Esophageal tamponade in the management of acute variceal hemorrhage. Dig Dis Sci. 1989;34:913-918.

Terés J, Planas R, Panes J, et al. Vasopressin/nitroglycerin infusion vs esophageal tamponade in the treatment of acute variceal bleeding: A randomized controlled trial. Hepatology. 1990;11:964-968.

Lo G-H, Lai K-H, Ng W-W, et al. Injection sclerotherapy preceded by esophageal tamponade versus immediate sclerotherapy in arresting active variceal bleeding: A prospective randomized trial. Gastrointest Endosc. 1992;38:421-424.

Collyer TC, Dawson SE, Earl D. Acute airway obstruction due to displacement of a Sengstaken-Blakemore tube. Eur J Anesthesiol. 2008;25:341-342.

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