Donovan Inniss, BS
Monica A. Tincopa, MD, MSc
Esophageal varices occur as a consequence of portal hypertension and may develop in up to 50% of patients with cirrhosis, but prevalence varies according to severity of underlying liver disease. Rate of variceal bleeding is dependent on severity of liver disease, size of varices, and presence of high-risk stigmata on endoscopy that is indicative of areas of thinning of the variceal wall. Approximately one-third of patients with varices will experience variceal bleeding with an annual rate of 10% to 15% per year.1,2 Urgent endoscopic therapy is used as first-line therapy in treating acute variceal bleeding. Endoscopy band ligation is the primary treatment modality. In patients whose bleeding cannot be controlled by endoscopic therapy, emergent therapies via intervention radiology such as transjugular intrahepatic portosystemic shunt (TIPS) should be considered.1,3 Balloon tamponade plays a role in management of variceal bleeding among patients in whom endoscopic therapy was unsuccessful in controlling bleeding and are in need of a “bridge” therapy in order to acutely stabilize active bleeding until further more definitive intervention can be performed.
The two most commonly used balloon tamponade systems are the Minnesota four-lumen esophagogastric tamponade tube and the three-lumen Sengstaken-Blakemore tube. The Minnesota tube incorporates an internal separate esophageal suction port in addition to the gastric suction port, gastric balloon inflation port, and esophageal balloon inflation port (Fig. 40.1). This esophageal suction port was added in order to help prevent aspiration of esophageal contents. When inflated, the balloons place pressure to decrease blood flow and thus help reduce active bleeding.
1. Acute, life-threatening bleeding from esophageal or gastric varices that is unresponsive to medical and endoscopic therapy.
2. Acute, life-threatening bleeding from esophageal or gastric varices when endoscopic therapy is unavailable.
1. Cessation of variceal bleeding
2. Recent surgery involving the esophagogastric junction
3. Known esophageal stricture
1. Poorly informed support staff
2. Large hiatal hernia
3. Incomplete lavage
4. Inability to demonstrate a variceal source of bleeding
5. Known severe esophageal ulceration (in these cases, the gastric balloon may be used but not the esophageal balloon)
1. Ensure appropriate volume resuscitation and pharmacologic therapy with vasoactive medication and antibiotics with a goal to restore and maintain hemodynamic stability.
2. Ensure airway protection. Patients with acute, large volume upper GI bleeds, particularly those who require balloon tamponade for treatment of severe variceal bleeding often require intubation for airway protection given high risk of aspiration in refractory variceal bleeding.
3. Perform endoscopy to confirm the source of bleeding, and attempt band ligation as a primary mode of treating acute variceal bleeding.
4. If endoscopy demonstrates large amounts of blood in the stomach, lavage the stomach with tap water using an adult gastric lavage or other large-bore tube.
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