Balloon Tamponade of Gastroesophageal Varices

  • Patient with known portal hypertension or prior variceal hemorrhage with substantial ongoing upper GI bleeding despite optimal medical therapy and for whom endoscopy is unavailable
  • Endoscopy readily available
  • Sedation should be provided during procedure. Head of bed should be elevated to 45 if possible or placed in left lateral decubitus position.
  • Stomach is evacuated with gastric lavage, NGT removed.
  • Currently there are two types of gastroesophageal balloon tamponade (GEBT) tubes available: The three-lumen Sengstaken-Blakemore tube (gastric balloon, esophageal balloon, and gastric aspiration) and the fourlumen Minnesota tube (which adds an esophageal aspiration port).
  • All balloons are collapsed and balloon ports clamped. Tube is then passed through mouth/nose into stomach. Suction is applied to gastric and esophageal aspiration lumens and position confirmed by X-ray. Increments of 100 mL of air are introduced through the gastric balloon inflation lumen until the recommended total volume (usually 500 mL) fills the gastric balloon. The intragastric balloon pressure is monitored. If high, balloon is likely in the esophagus and should be deflated and replaced into stomach. Once the gastric balloon is inflated, the tube is pulled back until the resistance of the diaphragm is firmly felt and the proximal end is secured using a traction device.
  • If blood is still detected in the gastric aspiration port (or in the esophageal aspiration port on a four-lumen tube) after lavage, the esophageal balloon should be inflated to the pressure recommended in the accompanying instructions (generally 30 to 45 mm Hg).
  • After bleeding has been controlled by the tamponade, the pressure in the esophageal balloon is generally reduced by 5 mm Hg every 3 hours until an intraesophageal balloon pressure of 25 mm Hg is achieved without ongoing bleeding.
  •  Ulceration of mucosal surfaces, mucosal ischemia inducing esophageal necrosis, aspiration pneumonia, asphyxiation, duodenal rupture
  •  Pressure should be maintained at the lowest level that will stop bleeding from each of the aspiration suction ports.