Endoscopic Placement of Sengstaken-Blakemore Tube in Torrential Esophageal Variceal Bleeding: An Innovative Use of an Old Tool

Abstract

Case: A 52-year-old Caucasian gentleman with known decompensated end stage liver disease presented to the emergency department with complaints of three to four episodes of large volume hematemesis over the preceding six hours. Patient was noted to be hypotensive and tachycardic on initial assessment. On initial laboratory investigations in the emergency room, he was noted to be anemic with a hemoglobin of 6.8 g/dl. Patient was admitted to the medical intensive care unit and aggressively resuscitated with packed red blood cells and isotonic saline. Octreotide intravenous infusion was started. Patient had recurrent hematemesis shortly after transfer to the ICU and was intubated for airway protection. An emergent esophagogastroduodenoscopy (EGD) was performed and profuse active bleeding from multiple large esophageal varices was noted. Several attempts at endoscopic band ligation and injection sclerotherapy failed to control bleeding. Methods: Endoscopy description: A Sengstaken-Blakemore tube was procured. A small snare was advanced through the channel of an EGD scope and was used to grasp the distal end of the Blakemore tube. Esophageal intubation was then performed and the scope was advanced into the stomach taking the Blakemore tube with it. The Blakemore tube was released from the snare. The endoscope was withdrawn slightly allowing adequate visualization of the gastric balloon. The gastric balloon was then inflated with 250cc of air and placed snug against the cardia. The endoscope was then withdrawn with visualization of the esophageal balloon. Hemostases was achieved as evidenced by stabilization of hemodynamics and hematocrit. Urgent referal for TIPS was made. Results: Torrential upper gastrointestinal bleeding from esophageal varices could be at times difficult to control by endoscopic techniques including endoscopic band ligation and injection sclerotherapy. Some of these patients are too unstable to undergo emergent TIPS. Sengstaken-Blakemore tube has been used in these situations in an attempt to achieve temporary hemostasis until further definitive therapy. Blind insertion of Blakemore tube has potential complications. These include coiling of the tube in the oropharynx, coiling of tube in distal esophagus, incomplete placement resulting in the gastric balloon residing in the esophagus. Inflation of the gastric balloon in the esophagus may lead to disastrous consequences including esophageal perforation and necrosis. All these can be avoided by careful placement of Blakemore tube while viewing through an endoscope. Conclusion: Endoscopic placement of Sengstaken-Blakemore tube is simple, safe and effective and should be favoured over blind insertion.