Sengstaken-Blakemore Research Articles

S2646 Role of Point-of-Care Ultrasound in Diagnosis of Upper GI Bleed Secondary to Aorto-Esophageal Fistula

Introduction: Aorto-esophageal fistula (AEF) is a rare etiology of upper gastrointestinal bleed (UGIB) with a high mortality rate. In patients with vascular pathology or aortic aneurysms presenting with hematemesis and Chiari’s triad (midthoracic pain, sentinel arterial hemorrhage and exsanguination after symptom-free interval), there should be high suspicion for AEF as mortality is high even with timely diagnosis and surgical intervention. Diagnostic endoscopy, aortography, or thoracic computed tomography angiography (CTA) are current standards of care but may be unobtainable in emergent cases. Here, we report a case of UGIB in which bedside Point-of-Care Ultrasound (POCUS) facilitated prompt diagnosis of AEF. Case Description/Methods: A 75-year-old male with history of diabetes, uncontrolled hypertension and abdominal aortic aneurysm presented with large volume hematemesis resulting in two episodes of PEA arrests. ROSC was achieved with aggressive hemodynamic support. Gastroenterology was consulted, but the patient was deemed too unstable for endoscopy. Octreotide and pantoprazole drips were initiated. Placement of a Blakemore tube was attempted. POCUS demonstrated descending aortic intraluminal flap consistent with aortic dissection. After stabilization, CTA was pursued which showed descending thoracic aortic aneurysm with penetrating ulcer and active extravasation into the subcarinal mediastinum. Vascular surgery was urgently consulted but the patient became increasingly unstable and ultimately expired. Discussion: AEF is a rare cause of UGIB that should be suspected in patients with large volume hematemesis, chest pain, hemodynamic compromise. Index of suspicion should be high in patients with a history of aortic aneurysm, esophageal malignancy, ingestion of foreign body or recent esophageal surgery. Temporization, rapid diagnosis, and surgical intervention are critical, but guideline directed diagnostic modalities are limited in hemodynamically unstable patients. Here, POCUS allowed prompt diagnosis several hours before the patient was stable enough for CTA. This case demonstrates that POCUS has a diagnostic role in massive UGIB in patients with a high pretest probability of vascular pathology and may limit unnecessary invasive testing in select patients who are unlikely to benefit from endoscopy. Further research is needed to determine the diagnostic role of POCUS in UGIB, but it should be considered in patients with high suspicion for AEF (Figure).Figure 1.: (A) POCUS showing descending aortic intraluminal flap consistent with aortic dissection. (B) CTA showing descending aortic aneurysm with penetrating ulcer resulting in hematoma of the subcarinal mediastinum.

238 A Comparison of Sengstaken-Blakemore Tube Insertion Performance Between Academic Emergency Medicine Attending and Resident Physicians

Sengstaken-Blakemore (SB) tube insertion is a rare but potentially life-saving skill used to manage emergent upper gastrointestinal bleeding. Although SB tube insertion is part of the emergency medicine (EM) curriculum, no widespread, objective standard exists to ensure competency. Moreover, practicing physicians have infrequent opportunities for application in the clinical environment. Therefore, variable skills in placing an SB tube may be observed. Our primary objective was to compare SB tube insertion performance between academic EM attending and resident physicians.

Aortoesophageal fistula: A case report

Introduction: Aortoesophageal fistula (AEF) is a rare and potentially lethal cause of upper gastrointestinal bleeding. Although several causes have been implicated in this condition, a ruptured thoracic aortic aneurysm remains the most common cause. Despite the challenge of differential diagnosis, this is a situation that requires prompt action with immediate hemorrhage control. Case Report: We report a case of a 56-year-old woman who presented with hemorrhagic shock secondary to AEF with no underlying cause identified, treated with Thoracic Endovascular Aortic Repair (TEVAR) after immediate bleeding control with a Sengstaken–Blakemore (SB) tube. Post-operatively the patient developed pneumonia and operative wound infection that were treated conservatively. At 24 months follow-up, the patient is asymptomatic and there is no clinical, analytical, or imagiological evidence of vascular graft infection. Conclusion: Survival outcomes have improved with the advent of endoluminal aortic stent therapies and TEVAR is currently considered a viable approach for AEF bleeding control in the emergency setting for unstable patients. However, long-term concerns remain since TEVAR is not a definitive treatment for AEF defect, leaving the patients at risk for AEF recurrence but also for stent graft infection. Resection of the esophagus with restoration of gastrointestinal continuity and vascular reconstruction can be performed in a one or two stage procedure and is the definitive treatment for AEF.

Survival outcomes and predictors of mortality, re-bleeding and complications for acute severe variceal bleeding requiring balloon tamponade.

BACKGROUNDAcute severe variceal bleeding (AVB) refractory to medical and endoscopic therapy is infrequent but associated with high mortality. Historical cohort studies from 1970-1980s no longer represent the current population as balloon tamponade is no longer first-line therapy for variceal bleeding; treatments including vasoactive therapies, intravenous antibiotics, endoscopic variceal band ligation are routinely used, and there is improved access to definitive treatments including transjugular intrahepatic portosystemic shunts. However, only a few studies from the current era exist to describe the practice of balloon tamponade, its outcomes, and predictors with a requirement for further updated information.AIMTo describe current management of AVB requiring balloon tamponade and identify the outcomes and predictors of mortality, re-bleeding and complications.METHODSA retrospective multi-centre cohort study of 80 adult patients across two large tertiary health networks from 2008 to 2019 in Australia who underwent balloon tamponade using a Sengstaken-Blakemore tube (SBT) were included for analysis. Patients were identified using coding for balloon tamponade. The primary outcome of this study was all-cause mortality at 6 wk after the index AVB. Secondary outcomes included re-bleeding during hospitalisation and complications of balloon tamponade. Predictors of these outcomes were determined using univariate and multivariate binomial regression.RESULTSThe all-cause mortality rates during admission and at 6-, 26- and 52 wk were 48.8%, 51.2% and 53.8%, respectively. Primary haemostasis was achieved in 91.3% and re-bleeding during hospitalisation occurred in 34.2%. Independent predictors of 6 wk mortality on multivariate analysis included the Model for Endstage Liver disease (MELD) score (OR 1.21, 95%CI 1.06-1.41, P = 0.006), advanced hepatocellular carcinoma (OR 11.51, 95%CI 1.61-82.20, P = 0.015) and re-bleeding (OR 13.06, 95%CI 3.06-55.71, P < 0.001). There were no relevant predictors of re-bleeding but a large proportion in which this occurred did not survive 6 wk (76.0% vs 24%). Although mucosal trauma was the most common documented complication after SBT insertion (89.5%), serious complications from SBT insertion were uncommon (6.3%) and included 1 patient who died from oesophageal perforation. CONCLUSIONIn refractory AVB, balloon tamponade salvage therapy is associated with high rates of primary haemostasis with low rates of serious complications. Re-bleeding and mortality however, remain high.

Risk factors for emergency endoscopic variceal ligation treatment failure of acute variceal bleeding

Objective To determine the risk factors for emergency endoscopic variceal ligation (EVL) failure in acute variceal bleeding (AVB). Methods Data from 161 cirrhosis patients with oesophageal variceal bleeding who underwent emergency EVL treatment at the Second Hospital of Hebei Medical University from January 2018 to May 2021 were retrospectively analysed. Enrolled patients were divided into a successful treatment group and a failed treatment group. The variables studied were demographic, clinical, imaging, laboratory, and endoscopic data from the enrolled patients. Results Of the enrolled patients, 19 patients experienced emergency EVL failure. Of these patients, nine underwent emergency endoscopic treatment again, six patients were treated with a Sengstaken–Blakemore tube for haemostasis and endoscopic treatment, four patients received drug therapy. The presence of portal vein thrombosis (PVT) in the failure group was higher than that in the success group (p < .05). Active bleeding on endoscopy was associated with emergency EVL failure for patients with Child–Pugh class C (p < .05). Conclusions Child–Pugh class C with active bleeding on endoscopy or the presence of PVT could increase the risk of emergency EVL failure. The patient’s condition should be fully evaluated before emergency endoscopic treatment to reduce the risk of failure.

大動脈瘤食道穿破に対してSBチューブが有効であった1例(Aortoesophageal fistula due to rupture of descending aortic aneurysm successfully treated by Sengstaken–Blakemore tube)

要旨 下行大動脈瘤食道穿破は治療が困難であり，致死率が高い病態である。今回，下行大動脈瘤食道穿破で大量吐血し，ショック状態で搬送され，SBチューブを用い，出血を制御し，その後ステントグラフト内挿術を行い救命できた症例を経験したので報告する。症例は60歳頃に腹部大動脈瘤に対して人工血管置換術を受けた80歳男性，散歩中に大量の吐血がみられたため救急搬送となった。来院時，血圧54/36mmHg，脈拍140/分とショック状態であり，吐血による出血性ショックと判断し，経口気管挿管と急速輸液を行った。循環が安定したため，造影CT検査を撮像したところ，下行大動脈に大動脈瘤および瘤からの造影剤の漏出，胸部中部食道への穿破を認めた。CT検査帰室後，再び大量吐血がみられ，急速輸液や輸血をしても血圧を維持できないため，SBチューブを挿入した。バルーン内圧を徐々に上昇させ，110mmHgまで内圧を上げたところで吐血がみられなくなった。急速輸液や輸血を継続しつつ，収縮期血圧90mmHg台で安定したため，来院後3時間程度で手術室に入室し，胸部大動脈ステント内挿術を施行してICU入院となった。その後も適宜輸血を要したが，全身状態は安定した。第12病日に食道抜去術を施行し，第20病日に一般病棟に転棟となった。大量吐血を伴った大動脈瘤食道穿破に対して，SBチューブを用いることで出血を制御し，救命し得たと考えられる。

Sengstaken-Blakemore tubes: a rescue system during liver transplantation

Sengstaken-Blakemore tubes: a rescue system during liver transplantation

Balloon Tamponade for the Management of Gastrointestinal Bleeding

BackgroundAcute gastrointestinal bleeding is a potentially life-threatening condition that requires rapid intervention. In critically ill patients who are refractory to other therapies, balloon tamponade devices can be lifesaving. ObjectiveWe provide a review of balloon tamponade devices for gastric and esophageal variceal bleeding for emergency clinicians. DiscussionBalloon tamponade is intended for hemodynamically unstable patients with massive gastrointestinal bleeding and inability to perform endoscopy, failed endoscopy, delay in endoscopy, or the need to stabilize before transfer. There are 3 main tamponade devices: the Linton–Nachlas tube, the Sengstaken–Blakemore tube, and the Minnesota tube. Each tamponade device has some unique features including the number of balloons and ports. We describe the technique with pearls and pitfalls for placement. ConclusionsIt is essential for emergency physicians to be familiar with balloon tamponade for acute gastrointestinal bleeding. We review the common balloon tamponade devices, and this article is intended to serve as a resource for those interested in expanding their knowledge of balloon tamponade. © 2022 Elsevier Inc.

Massive Upper Gastrointestinal Bleeding.

This case is targeted to emergency medicine residents of all levels. Upper gastrointestinal bleeding (UGIB) is a common chief complaint encountered in the emergency department, resulting in over 500,000 hospitalizations and 20,000 deaths annually in the United States.1 The diagnosis and management of UGIB in stable patients is typically fairly straightforward. However, there are a number of circumstances where the treatment of UGIB is much more challenging, and emergency medicine (EM) physicians should be familiar with, and have experience managing, these difficult presentations. Massive UGIB can necessitate the need for management of a difficult airway in the setting of airway contamination, as well as placement of a gastroesophageal balloon tamponade device. The appropriate use and indications for performing this high-risk/low-frequency procedure requires dedicated practice. Furthermore, the management of gastrointestinal hemorrhage in a patient with a religious objection to the administration of blood products, including Jehovah's Witnesses, can be especially challenging and requires knowledge of alternative therapies to support blood pressure, oxygen carrying capacity, and decrease coagulopathy.2,3. By the end of this simulation, learners will be able to: 1) manage a hypotensive patient with syncope and hematemesis, 2) pharmacologically manage an acute UGIB addressing the various causes, 3) recognize worsening clinical status and intervene by performing difficult airway management, 4) place a gastroesophageal balloon tamponade device. This simulation was conducted with a high-fidelity mannequin with a separate medium-fidelity intubating mannequin that was modified to allow rapid filling of the oropharynx with simulated blood. Due to the COVID-19 pandemic, a total of six EM residents in various levels of training participated in the simulated patient encounter while the rest of the learners watched the simulation and participated in the debrief via video conference. Following the simulation and debrief session, all the residents, including those who participated in-person and via video conference, were sent a survey via surveymonkey.com to assess the educational quality of the simulation. Overall residents expressed positive feedback on the scenario, noting that the case was realistic, appropriately complex, and improved their medical knowledge and procedural skills. This case has a mixture of high-fidelity and medium-fidelity components which can be easily reproduced. The case was extremely useful in teaching EM residents of all levels not only how to manage large volume UGIB in a patient who is also a Jehovah's Witness, but also how to manage the airway and place a gastroesophageal balloon tamponade device. The case starts with a patient presenting with syncope and as the case unfolds, the patient's clinical status deteriorates, requiring learners to resuscitate, intubate, and obtain a gastroesophageal balloon tamponade.Residents commented that managing this case of an UGIB was extremely challenging because it exposed and filled important gaps in both their knowledge and procedural skills. Residents struggled most with identifying alternative therapies to blood products in patients with religious objections, and the step-by-step process of placing a Blakemore tube. Upper gastrointestinal bleed, hemorrhagic shock, Jehovah's Witness, difficult airway.

Iatrogenic Esophagopleural Fistula After the Management of Acute Variceal Hemorrhage With Minnesota Tube Placement

ABSTRACTAn esophagopleural fistula (EPF) is a rare condition. EPFs are typically of spontaneous, iatrogenic, or neoplastic origin. A 50-year-old man with hepatitis C and alcoholic cirrhosis presented with a history of recurrent variceal hemorrhage requiring esophageal banding, Minnesota tube placement, and a transjugular intrahepatic portosystemic shunt. His hospital course after esophageal perforation and EPF was complicated by acute respiratory failure and empyema, necessitating intubation and thoracostomy tube placement. To the best of our knowledge, this is the first reported case of EPF secondary to Minnesota tube placement. The EPF completely healed after endoscopic repair.

Repair of a three-way congenital bronchoesophageal fistula in an adult patient: a case report

BackgroundThe incidence of congenital bronchoesophageal fistulas in adults is rare. Most fistulas discovered in adulthood are often small and can be repaired with a simple one-step method.Case presentationA 46-year-old female patient complained of a 2-month history of chocking, coughing, and a 12 kg drop in weight. The bronchofiberscopy and gastroscopy showed a large fistula, which extended from the esophagus to the main bronchus on both sides, thus forming a special three-way channel which has never been reported. This case was challenging both to the anesthetists and surgeons. The patient was intubated with a sengstaken-blakemore tube, and then received segmental esophageal resection, anastomotic reconstruction, and double-flap repair with esophagus segment in situ.ConclusionWhen the fistula in BEF is large or complicated, appropriate surgical methods should be meticulously designed according to the condition of the patient. The problem of anesthesia intubation should be solved first, to allow a smooth operation. Secondly, a double-layer repair of the airway fistula by using esophageal wall tissues as patch materials is proposed.

868 The management of acute lower gastrointestinal bleeding using a Sengstaken-Blakemore tube

Abstract Introduction Acute lower gastrointestinal haemorrhage can potentially be life-threatening. We present a case of a massive rectal bleed which was managed successfully with a balloon tamponade device designed for upper gastrointestinal haemorrhage. Presentation of case A 75-year-old gentleman, with a history of human immunodeficiency virus and cirrhosis with portal hypertension, presented with bright red rectal bleeding. Investigations showed a low haemoglobin level (74 g/L) and deranged clotting. Oesophago-gastro-duodenoscopy demonstrated no fresh or altered blood. Flexible sigmoidoscopy revealed active bleeding from a varix within the anterior rectal wall 4 cm from the anal verge. Efforts to stop the bleeding, including endoscopic clips, adrenaline injection and rectal packing, were unsuccessful and the patient became haemodynamically unstable. A Sengstaken-Blakemore tube was inserted per rectum and the gastric balloon was inflated to tamponade the lower rectum. The oesophageal balloon was then inflated to hold the gastric balloon firmly in place. A computed tomography angiogram demonstrated no evidence of haemorrhage with balloon tamponade. After 36 h, the balloon was removed with no further episodes of bleeding. Discussion The application of a balloon tamponade device should be considered in the management algorithm for acute lower gastrointestinal bleed. Advantages include its rapid insertion, immediate results and ability to measure further bleeding after the catheter has been placed. Conclusions Sengstaken-Blakemore tube per rectum may effectively control massive low rectal bleeding when alternative methods have been unsuccessful.

S2555 Right Hepatic Artery Pseudoaneurysm: A Rare Complication of Biliary Stent Placement

Introduction: Formation of pseudoaneurysm is a rare but serious adverse event of biliary stenting. We present a case of a patient who presented with massive upper gastrointestinal bleeding two months after biliary stent insertion. Angiography revealed a right hepatic artery pseudoaneurysm which was successfully treated with transcatheter arterial embolization. Because bleeding may be fatal, timely diagnosis of the condition is important. Case Description/Methods: A 65-year-old-man with a past medical history of recurrent gallstone pancreatitis underwent Endoscopic Retrograde Cholangio-Pancreatography (ERCP) with sphincterotomy and fully covered metal stent placement was admitted to our hospital for severe hematemesis. Labs revealed a drop in hemoglobin from 7.6 to 5.8. After endotracheal intubation, activation of the massive transfusion protocol (MTP) Minnesota tube placement, emergent esophagogastroduodenoscopy (EGD) was performed at the bedside, which showed a large amount of clotted blood but no active bleed. The next day, again he developed severe upper gastrointestinal bleeding leading to hypovolemic shock. MTP was activated again, and a Minnesota tube reinserted. After intensive resuscitation, a computed tomography angiography (CTA) was performed which showed a 6 cm large bilobed pseudoaneurysm in the porta hepatis appears to be arising from the hepatic artery. Successful embolization of the common hepatic artery was performed without complications. No recurrent bleeding occurred over the following days. Discussion: This case demonstrates a rare complication of biliary stents which was successfully treated with transcatheter arterial embolization. It is important to consider that a pseudoaneurysm is a potential adverse event caused by a biliary stent because timely diagnosis and treatment are required to prevent fatal hemorrhage and death.Figure 1.: A. Large bilobed pseudoaneurysm in the porta hepatis appears to be arising from the hepatic artery and abuts the distal gastric antrum/proximal duodenum. B. Injection from celiac artery demonstrating a bilobed pseudoaneurysm originating from the common hepatic artery/proximal right hepatic artery at the level of the intersection with the biliary stent. C. Post IR embolization CTA showing common hepatic artery without opacification and previously seen pseudoaneurysm.

The Role of Haemostasis Course in Increasing Knowledge and Skills in Managing Upper Gastrointestinal Bleed of the Delegates: A British Society of Gastroenterology's Endoscopy Quality Improvement Programme, Yorkshire Project.

IntroductionAn acute upper gastrointestinal bleed (AUGIB) is a fatal and prevalent medical emergency if not appropriately treated in a timely fashion.AimThe aim of this project was to compare the knowledge and skills of the participants in managing upper gastrointestinal bleeding (UGIB) before and after a one-day UGIB haemostasis course.MethodsA one-day haemostasis course in line with the British Society of Gastroenterology’s Endoscopy Quality Improvement Project Initiative was organised at the Sheffield Teaching Hospitals National Health Service (NHS) Trust. The course included lectures on UGIB and its management, which was followed by hands-on training on adrenaline injection, variceal banding, clip placement, thermal therapy, Hemospray® use, Sengstaken-Blakemore tube placement, and Danis stent placement via porcine or plastic models. Pre- and post-course feedback questionnaires consisting of self-assessed ratings related to knowledge, skills, and behaviour relevant to UGIB were offered to all delegates. Two-tailed Wilcoxon signed-rank test was used to compare the results.ResultsA total of 36 individuals attended the course. Delegates had an average endoscopy procedure count of 583. The cohort ranged from different fields of medicine, including gastroenterology consultants and junior doctors. Ten of the delegates were Joint Advisory Group-certified in upper gastrointestinal endoscopy. Feedback datasheets were returned by 22 delegates. Significant improvements were reported post-course (p < 0.001), especially in the hands-on and behavioural areas.ConclusionOverall, there was a significant improvement in the knowledge, procedural skills, and confidence of the delegates in the management of an AUGIB post-course. We recommend not only to include this course in gastrointestinal training but also to conduct a course such as this for consultants and junior doctors who wish to undergo gastrointestinal training in the future.

A Sengstaken–Blakemore tube to rescue respiratory failure due to oesophageal-pulmonary fistula

A Sengstaken–Blakemore tube to rescue respiratory failure due to oesophageal-pulmonary fistula

Just-in-time clinical video review improves successful placement of Sengstaken-Blakemore tube by emergency medicine resident physicians: A randomized control simulation-based study.

Successful completion of life-saving procedures may benefit from a concise just-in-time (JIT) intervention. Video is an optimal medium for JIT training, but currently available video-based references are not optimized for a JIT format, especially in time-pressured situations prior to high-risk clinical contexts. We aimed to create and evaluate the efficacy of a brief video review of emergent Sengstaken-Blakemore tube (SBT) insertion for acutely decompensating variceal hemorrhage when used just prior to clinical performance in a simulated setting. We created a less than 3-minute audio-optional JIT training video on SBT insertion. We recruited emergency medicine resident physicians to participate in a simulation scenario in which they had to quickly place an SBT. Participants were randomized to either a 3-minute procedure review by any media they chose (control) or review of the JIT video (intervention). Performance on a checklist created by a multidisciplinary group of SBT experts (passing score > 18 and maximum=28) served as the primary outcome. We analyzed performance in checklist scores controlling level of training through a one-way analysis of covariance (ANCOVA). We analyzed rates of passing scores via a chi-square analysis. We randomized 32 participants to media review (control) or JIT video (intervention). The intervention group had an overall mean (±SD) performance of 19.8 (±9.0) and the control group had a mean (±SD) score of 6.6 (±7.4). After adjusting for postgraduate year, we found a significant difference in final checklist scores between the two groups (mean difference=12.8, 95% confidence interval [CI]= 7.6 to 18.0). Percentages of participants reaching a minimum passing score were two of 16 (12.5%) in the control group and 10 of 16 (62.5%) in the intervention group (odds ratio=11.7, 95% CI=9.9 to 13.5). Cohen's kappa indicated substantial agreement (κ=0.714) between reviewer scores. A readily available, focused, audio-optional JIT video increased performance for SBT insertion in a simulated setting. Future work may include testing of this format for more commonly performed emergency procedures and determination of effect on bedside performance in the clinical setting.

Impact of Risk and Volume on Procedural Traning of Pulmonary and Critical Care Fellows.

Background: Invasive procedures are a core aspect of pulmonary and critical care practice. Procedures performed in the intensive care unit can be divided into high-risk, low-volume (HRLV) procedures and low-risk, high-volume (LRHV) procedures. HRLV procedures include cricothyroidotomy, pericardiocentesis, Blakemore tube placement, and bronchial blocker placement. LRHV procedures include arterial line placement, central venous catheter placement, thoracentesis, and flexible bronchoscopy. Despite the frequency and importance of procedures in critical care medicine, little is known about the similarities and differences in procedural training between different Pulmonary and Critical Care Medicine (PCCM) and Critical Care Medicine (CCM) training programs. Furthermore, differences in procedural training practices for HRLV and LRHV procedures have not previously been described.Objective: To assess procedural training practices in PCCM and CCM fellowship programs in the United States, and compare differences in training between HRLV and LRHV procedures.Methods: A novel survey instrument was developed and disseminated to PCCM and CCM program directors and associate program directors at PCCM and CCM fellowship programs in the United States to assess procedural teaching practices for HRLV and LRHV procedures.Results: The survey was sent to 221 fellowship programs, 168 PCCM and 34 CCM, with 70 unique respondents (31.7% response rate). Of the procedural educational strategies assessed, each strategy was used significantly more frequently for LRHV versus HRLV procedures. The majority of respondents (51.1%) report having no dedicated training for HRLV procedures versus 6.9% reporting no dedicated training for any LRHV procedure (P < 0.001). For HRLV procedures, 76.9% of respondents indicated that there was no set number of procedures required to determine competency, versus 25.3% for LRHV procedures (P < 0.001). For LRHV procedures, fellows were allowed to perform procedures independently without supervision 21.7% of the time versus 3.9% for HRLV procedures (P = 0.004). Program directors’ confidence in their ability to determine fellows’ competence in performing procedures was significantly lower for HRLV versus LRHV versus HRLV procedures (P < 0.001).Conclusion: Significant differences exist in procedural training education for PCCM and CCM fellows for LRHV versus HRLV procedures, and awareness of this discrepancy presents an opportunity to address this educational gap in PCCM and CCM fellowship training.

Non-Operative Management in Oesophagic Tear Due to Sengstaken Tube

Non-Operative Management in Oesophagic Tear Due to Sengstaken Tube

Emergency tips recanalisation and gastroesophageal varices embolisation with an ethylene vinyl alcohol copolymer agent (Squid) and detachable coils

Transjugular intrahepatic portosystemic shunt (TIPS) is currently indicated as first therapeutic option in the main complications of portal hypertension, including bleeding gastroesophageal varices and refractory ascites. In case of bleeding gastroesophageal varices, an adjuvant embolisation within TIPS can be useful to prevent rebleeding. In the present technical note, the management in emergency of a patient with haemorrhagic shock due to bleeding gastroesophageal varices and occluded TIPS is reported. TIPS recanalisation with an adjunctive stent and high-pressure balloon angioplasty and gastroesophageal varices embolisation using detachable coils and a non-adhesive liquid embolic agent were performed during the same emergent procedure. After the procedure, clinical stabilisation of the patient was achieved, with blood transfusions suspension and Blakemore tube removal. At 6 months, regular TIPS patency at colour Doppler and no rebleeding episodes were recorded. To our knowledge, whilst coils are routinely used for varices embolisation, non-adhesive liquid embolic agents have been never mentioned. Liquid embolic agents seem to provide a stable plug strengthening the embolising action of the coils. Further studies involving a cohort of patients with long-term follow-up will be necessary to confirm whether this association can be more effective than coils alone in gastroesophageal varices embolisation.

S1979 Holding Pressure: The Use of a Sengstaken-Blakemore Tube in the Setting of Atrioesophageal Fistula Hemorrhage

S1979 Holding Pressure: The Use of a Sengstaken-Blakemore Tube in the Setting of Atrioesophageal Fistula Hemorrhage