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Sengstaken-Blakemore Tube Placement

  • Author: Richard Treger, MD; Chief Editor: Vikram Kate, MBBS, PhD, MS, FRCS, FRCS(Edin), FRCS(Glasg), FACS, FACG, FIMSA, MAMS, MASCRS  more...
 
Updated: Apr 03, 2015
 

Overview

Balloon tamponade of bleeding esophageal varices was described as early as the 1930s. A double-balloon tamponade system was developed by Sengstaken and Blakemore in 1950 and has undergone relatively few changes up to the current day.[1, 2, 3] The three major components of a Sengstaken-Blakemore tube are as follows (see the image below):

  • Gastric balloon
  • Esophageal balloon
  • Gastric suction port
    Sengstaken-Blakemore tube. Image courtesy of Richa Sengstaken-Blakemore tube. Image courtesy of Richard Treger, MD.

The addition of an esophageal suction port to help prevent aspiration of esophageal contents resulted in what is called the Minnesota tube. Another nasogastric (NG) device with a single gastric balloon is most effective at terminating bleeding from gastric varices and is known as the Linton-Nachlas tube (see the image below).[4]

Linton-Nachlas tube. Image courtesy of Richard Tre Linton-Nachlas tube. Image courtesy of Richard Treger, MD.

The advent of endoscopy has reduced the use of balloon tamponade, but the use of such devices can still be temporizing or lifesaving, despite their potential for serious complications.[5, 6, 7, 8, 9]

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Indications

Indications for placement of a Sengstaken-Blakemore tube include the following:

  • Acute life-threatening bleeding from esophageal or gastric varices that does not respond to medical therapy (including endoscopic hemostasis and vasoconstrictor therapy) [10, 11, 12]
  • Acute life-threatening bleeding from esophageal or gastric varices when endoscopic hemostasis and vasoconstrictor therapy are unavailable

Chen et al have described a case in which a Sengstaken-Blakemore tube was successfully used for nonvariceal distal esophageal bleeding (from severe ulcerative esophagitis) after conventional medical and endoscopic therapy had failed.[13]

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Contraindications

Contraindications for placement of a Sengstaken-Blakemore tube include the following:

  • Variceal bleeding stops or slows
  • Recent surgery that involved the esophagogastric junction
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Anesthesia

Topical anesthetic (spray and jelly) is used for the oropharynx. (For more information, see Anesthesia, Topical.) Intubation and sedation are indicated for most patients.

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Equipment

Equipment used for placement of a Sengstaken-Blakemore tube includes the following:

  • Gastroesophageal balloon tamponade tube
  • Y-tube connector or similar adapter, if not already part of the tamponade balloon ports (see the first and second images below)
  • Traction device or setup (see the third image below)
  • Manual manometer or sphygmomanometer (see the fourth image below)
  • Vacuum suction device with suction tubing and connectors (see the fifth image below)
  • Tube clamps (4)
  • Large (60 mL) irrigating syringe (catheter tip)
  • Soft restraints
  • Water-soluble lubricating jelly
  • Scissors for emergency balloon decompression
    Y-tube connector. Image courtesy of Richard Treger Y-tube connector. Image courtesy of Richard Treger, MD.
    Lopez valve. Image courtesy of Richard Treger, MD. Lopez valve. Image courtesy of Richard Treger, MD.
    Pulley device for traction. Image courtesy of Rich Pulley device for traction. Image courtesy of Richard Treger, MD and Stanley Dea, MD.
    Sphygmomanometer. Image courtesy of Richard Treger Sphygmomanometer. Image courtesy of Richard Treger, MD.
    Vacuum suction device. Image courtesy of Richard T Vacuum suction device. Image courtesy of Richard Treger, MD.
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Positioning

Elevate the head of the bed to 45°, and position the patient on the bed. The left lateral decubitus position is an acceptable alternative.

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Technique

The following instructions pertain to the Sengstaken-Blakemore and Minnesota tubes. However, the same principles apply to the Linton-Nachlas tube, even though it has only a single gastric balloon.

Control of the patient is essential. Routine use of soft restraints and medications for sedation should be considered in most patients.

The threshold to perform endotracheal intubation should be low, as the risk of regurgitation and aspiration is extremely high. To minimize this risk, perform nasogastric (NG) lavage and maximal stomach evacuation before placing an esophageal tamponade tube.

Ensure that all the appropriate equipment is present. Ensure that the balloons on the tamponade tube are free of leaks; optimally, balloon integrity should be tested while the balloons are submerged under water.

An optional step is as follows: If monitoring gastric balloon pressure, inflate the gastric balloon in increments (typically 100 mL) up to the maximum recommended volume (usually 500 mL) while the pressure is measured with the manometer. Note the pressure at each given volume. (See the image below.)

Setup for measuring gastric or esophageal balloon Setup for measuring gastric or esophageal balloon pressure. Image courtesy of Richard Treger, MD.

Another optional step is the following: If the NG tube is used, tie it along the course of the tube with silk sutures, with the tip of the NG tube 3-4 cm proximal to the esophageal balloon. This step is not required if the tube is one that has esophageal aspiration ports (ie, a Minnesota tube). (See the image below.)

NG tube tied along Sengstaken-Blakemore tube. Imag NG tube tied along Sengstaken-Blakemore tube. Image courtesy of Richard Treger, MD.

Position the patient appropriately, and anesthetize the posterior pharynx and nostrils with a topical anesthetic.

Suction all air from the gastric and esophageal balloons. (See the image below.)

Air being suctioned from gastric balloon using 60- Air being suctioned from gastric balloon using 60-mL syringe. Image courtesy of Richard Treger, MD.

Clamp the balloon ports or insert the plastic plugs into the lumens (if provided with the tube). (See the image below.)

Plastic plug being inserted into lumen of balloon Plastic plug being inserted into lumen of balloon port. Image courtesy of Richard Treger, MD.

Coat the balloons on the tube with water-soluble lubricating jelly. Pass the tube to at least the 50-cm mark. The tube can be passed through the nostrils or, preferably, through the mouth. The oral route is especially preferred in intubated patients. (See the image below.)

Illustration of placement of Sengstaken-Blakemore Illustration of placement of Sengstaken-Blakemore tube. Image courtesy of CR Bard, Inc.

Apply suction to the gastric and esophageal aspiration ports.

A third optional step is as follows: If monitoring gastric balloon pressure, remove the tube clamps (or plastic plugs, if used) from the gastric balloon inflation ports. Introduce increments of air (usually 100 mL) through the gastric balloon inflation port while the pressure is again measured with the manometer. If, at any given increment, the gastric balloon pressure is 15 mm Hg greater than readings previously obtained during testing (ie, before intubation), then deflate the balloon; it may be located in the esophagus.

When the gastric balloon is correctly positioned in the stomach, inflate it with the full recommended volume of air (usually 450-500 mL), then clamp the air inlet and pressure-monitoring outlet. Check proper placement by irrigating the gastric aspiration port with water while auscultating over the stomach. If correct tube placement is at all uncertain or if time permits, obtain a portable chest radiograph.

Pull the tube back gently until resistance is felt against the diaphragm.

Secure the proximal end of the tube using a traction device. A pulley device can be used to maintain the desired 0.45-0.91 kg (1-2 lb) of traction. A 500-mL bag of intravenous fluid can serve as a convenient initial weight. Alternatively, tubes can be secured with tape to the mouth guard of a football helmet. A foam rubber cuff, which is generally included in the package with the tube itself, can be used to maintain traction against the nose if the tube has been inserted through the nostrils. (See the image below.)

Pulley device for traction. Image courtesy of Rich Pulley device for traction. Image courtesy of Richard Treger, MD and Stanley Dea, MD.

If bleeding persists from the gastric aspiration port (or from the esophageal aspiration port on a four-lumen tube), inflate the esophageal balloon to the lowest pressure needed to stop bleeding (usually 30-45 mm Hg), then clamp the port for the esophageal balloon. Check the balloon pressure periodically. (See the image below.)

Illustration of setup for inflating and measuring Illustration of setup for inflating and measuring pressure in esophageal balloon. Image courtesy of CR Bard, Inc.

If bleeding persists from the gastric aspiration port after inflation of the gastric and esophageal balloons, increase the external traction on the tube (to a maximum of 1.1 kg [2.5 lb]). In this case, the bleeding typically originates from a gastric rather than an esophageal varix.

Confirm correct tube position with an immediate portable radiograph.

After bleeding has been controlled, reduce the pressure in the esophageal balloon by 5 mm Hg every 3 hours until 25 mm Hg is reached without bleeding; this pressure is generally maintained for the next 12-24 hours. If bleeding is controlled, deflate the esophageal balloon for 5 minutes every 6 hours to help prevent esophageal necrosis.

Once the tube is satisfactorily positioned, it is generally left in place for 24 hours. If bleeding recurs, the gastric balloon and, if necessary, the esophageal balloon may be reinflated for an additional 24 hours. However, in view of the high mortality among patients who rebleed, alternatives such as sclerotherapy and transjugular intrahepatic portacaval shunting (TIPS) should be considered.

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Pearls

In most cases, the esophageal balloon is not inflated during the initial placement of the tube. Never inflate the esophageal balloon before the gastric balloon.

Keep a pair of scissors near the patient at all times in case the balloons migrate superiorly and obstruct the airway. The whole tube can be cut and removed.

Direct pressure from the tube can cause mucosal ulceration. Perform frequent examinations to ensure that the tube is not placing excessive force on any given surface.

Generally, the esophageal tamponade tube is a temporizing measure and should not be left in place for more than 24 hours.

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Complications

Aspiration[11] is probably the most frequent major complication of Sengstaken-Blakemore tube placement. The greatest risk of aspiration occurs during insertion. The risk of aspiration can be minimized by evacuating the stomach prior to tube placement and maintaining a low threshold for endotracheal intubation.[14]

Asphyxiation[15, 16] is caused by proximal migration of the tube and can be prevented with endotracheal intubation. If tube migration results in airway obstruction, cutting across all the tube lumens just distal to the points of bifurcation allows immediate extraction of the entire tube.

Esophageal perforation or rupture[17] can occur with inflation of a gastric balloon that is inadvertently placed in the esophagus or can be secondary to esophageal mucosal necrosis that results from excessive or prolonged inflation of the esophageal balloon.

Minor complications include the following:

  • Pain
  • Pharyngeal and gastroesophageal erosions and ulcers caused by local pressure effects
  • Pressure necrosis of the nose, lips, and tongue
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Contributor Information and Disclosures
Author

Richard Treger, MD Assistant Clinical Professor of Medicine, Division of Nephrology, Greater Los Angeles VA Healthcare System, University of California, Los Angeles, David Geffen School of Medicine

Disclosure: Nothing to disclose.

Coauthor(s)

Thomas P Graham, MD, FACEP Clinical Professor of Medicine, Emergency Medicine, University of California at Los Angeles School of Medicine, UCLA Medical Center

Thomas P Graham, MD, FACEP is a member of the following medical societies: American College of Emergency Physicians, Wilderness Medical Society

Disclosure: Nothing to disclose.

Stanley K Dea, MD Chief of Endoscopy, Acting Chief of Gastroenterology, Consulting Gastroenterologist Olive View-University of California at Los Angeles Medical Center; Director of Enteral Feeding, West Los Angeles Veterans Affairs Medical Center; Director of Endoscopic Training, University of California at Los Angeles Affiliated Training Program in Gastroenterology

Stanley K Dea, MD is a member of the following medical societies: American Society for Gastrointestinal Endoscopy, Southern California Society of Gastroenterology

Disclosure: Nothing to disclose.

Specialty Editor Board

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Luis M Lovato, MD Associate Clinical Professor, University of California, Los Angeles, David Geffen School of Medicine; Director of Critical Care, Department of Emergency Medicine, Olive View-UCLA Medical Center

Luis M Lovato, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Emergency Physicians, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Chief Editor

Vikram Kate, MBBS, PhD, MS, FRCS, FRCS(Edin), FRCS(Glasg), FACS, FACG, FIMSA, MAMS, MASCRS Professor of General and Gastrointestinal Surgery and Senior Consultant Surgeon, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), India

Vikram Kate, MBBS, PhD, MS, FRCS, FRCS(Edin), FRCS(Glasg), FACS, FACG, FIMSA, MAMS, MASCRS is a member of the following medical societies: American College of Gastroenterology, American College of Surgeons, American Society of Colon and Rectal Surgeons, Royal College of Surgeons of England, Royal College of Physicians and Surgeons of Glasgow, Royal College of Surgeons of Edinburgh

Disclosure: Nothing to disclose.

Additional Contributors

Gil Z Shlamovitz, MD, FACEP Associate Professor of Clinical Emergency Medicine, Keck School of Medicine of the University of Southern California; Chief Medical Information Officer, Keck Medicine of USC

Gil Z Shlamovitz, MD, FACEP is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association

Disclosure: Nothing to disclose.

Acknowledgements

Thanks to CR Bard, Inc, for their assistance.

The authors and editors of Medscape Drugs & Diseases gratefully acknowledge the assistance of Lars J Grimm, MD, MHS, with the literature review and referencing for this article.

References
  1. Bauer JJ, Kreel I, Kark AE. The use of the Sengstaken-Blakemore tube for immediate control of bleeding esophageal varices. Ann Surg. 1974 Mar. 179(3):273-7. [Medline].

  2. Boyce HW Jr. Modification the Sengstaken-Blakemore balloon tube. Nord Hyg Tidskr. 1962 Jul 26. 267:195-6. [Medline].

  3. Sengstaken RW, Blakemore AH. Balloon tamponage for the control of hemorrhage from esophageal varices. Ann Surg. 1950 May. 131(5):781-9. [Medline].

  4. Chojkier M, Conn HO. Esophageal tamponade in the treatment of bleeding varices. A decadel progress report. Dig Dis Sci. 1980 Apr. 25(4):267-72. [Medline].

  5. Conn HO, Simpson JA. Excessive mortality associated with balloon tamponade of bleeding varices. A critical reappraisal. JAMA. 1967 Nov 13. 202(7):587-91. [Medline].

  6. Paquet KJ, Feussner H. Endoscopic sclerosis and esophageal balloon tamponade in acute hemorrhage from esophagogastric varices: a prospective controlled randomized trial. Hepatology. 1985 Jul-Aug. 5(4):580-3. [Medline].

  7. Yoshida H, Mamada Y, Taniai N, Tajiri T. New methods for the management of gastric varices. World J Gastroenterol. 2006 Oct 7. 12(37):5926-31. [Medline].

  8. Yan BM, Lee SS. Emergency management of bleeding esophageal varices: drugs, bands or sleep?. Can J Gastroenterol. 2006 Mar. 20(3):165-70. [Medline].

  9. [Guideline] World Gastroenterology Organisation (WGO). Esophageal Varices. Milwaukee, WI: World Gastroenterology Organisation (WGO); 2014. 1-14.

  10. 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 May. 27(5):413-6. [Medline].

  11. Panes J, Teres J, Bosch J, Rodes J. Efficacy of balloon tamponade in treatment of bleeding gastric and esophageal varices. Results in 151 consecutive episodes. Dig Dis Sci. 1988 Apr. 33(4):454-9. [Medline].

  12. D'Amico G, Pagliaro L, Bosch J. The treatment of portal hypertension: a meta-analytic review. Hepatology. 1995 Jul. 22(1):332-54. [Medline].

  13. Chen YI, Dorreen AP, Warshawsky PJ, Wyse JM. Sengstaken-Blakemore tube for non-variceal distal esophageal bleeding refractory to endoscopic treatment: a case report & review of the literature. Gastroenterol Rep (Oxf). 2014 Nov. 2(4):313-5. [Medline]. [Full Text].

  14. Edlich RF, Landé AJ, Goodale RL, Wangensteen OH. Prevention of aspiration pneumonia by continuous esophageal aspiration during esophagogastric tamponade and gastric cooling. Surgery. 1968 Aug. 64(2):405-8. [Medline].

  15. Collyer TC, Dawson SE, Earl D. Acute upper airway obstruction due to displacement of a Sengstaken-Blakemore tube. Eur J Anaesthesiol. 2008 Apr. 25(4):341-2. [Medline].

  16. Agarwal R, Aggarwal AN, Gupta D. Endobronchial malposition of Sengstaken-Blakemore tube. J Emerg Med. 2008 Jan. 34(1):93-4. [Medline].

  17. Pinto-Marques P, Romaozinho JM, Ferreira M, Amaro P, Freitas D. Esophageal perforation--associated risk with balloon tamponade after endoscopic therapy. Myth or reality?. Hepatogastroenterology. 2006 Jul-Aug. 53(70):536-9. [Medline].

 
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Sengstaken-Blakemore tube. Image courtesy of Richard Treger, MD.
Linton-Nachlas tube. Image courtesy of Richard Treger, MD.
Lopez valve. Image courtesy of Richard Treger, MD.
Pulley device for traction. Image courtesy of Richard Treger, MD and Stanley Dea, MD.
Sphygmomanometer. Image courtesy of Richard Treger, MD.
Vacuum suction device. Image courtesy of Richard Treger, MD.
Setup for measuring gastric or esophageal balloon pressure. Image courtesy of Richard Treger, MD.
NG tube tied along Sengstaken-Blakemore tube. Image courtesy of Richard Treger, MD.
Air being suctioned from gastric balloon using 60-mL syringe. Image courtesy of Richard Treger, MD.
Plastic plug being inserted into lumen of balloon port. Image courtesy of Richard Treger, MD.
Illustration of placement of Sengstaken-Blakemore tube. Image courtesy of CR Bard, Inc.
Illustration of setup for inflating and measuring pressure in esophageal balloon. Image courtesy of CR Bard, Inc.
Y-tube connector. Image courtesy of Richard Treger, MD.
 
 
 
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