Esophageal balloon tamponade device

An esophageal balloon tamponade device is a form of balloon catheter designed to exert direct pressure on bleeding gastro-esophageal varices in order to obtain hemostasis. It is considered a temporizing measure in hemodynamically unstable patients in whom endoscopic (or angiographic) intervention is delayed or unsuccessful.

Terminology

Esophageal balloon tamponade devices are usually one of three eponymous products available. These devices differ due to ⁹:

• number of balloons

• aspiration ports

• volume of air accommodated by the gastric balloon

Types of tamponade device

• Sengstaken-Blakemore tube

  • has both gastric and esophageal balloons

    • the latter only utile when inflation of the gastric balloon does not achieve hemostasis

    • the esophageal balloon is inflated based on measured pressure as opposed to absolute volume ⁶

  • single gastric aspiration port

    • requires the separate insertion of an orogastric or nasogastric tube for esophageal suctioning

  • gastric balloon capacity of 250-300 mL

• Minnesota tube

  • both gastric and esophageal balloons

  • only device with both gastric and esophageal aspiration ports

  • gastric balloon can accommodate approximately 500 mL

• Linton-Nachlas tube

  • gastric balloon only

  • contains a single gastric aspiration port

  • gastric balloon capacity of approximately 600 mL

Indications

Placement is indicated in patients with refractory, massive upper gastrointestinal bleeding due to a probable or confirmed variceal hemorrhage, who are hemodynamically unstable, and in whom definitive endoscopic measures (such as sclerotherapy or banding) or interventional procedures (e.g. creation of a transjugular intrahepatic portosystemic shunt) are ²:                       

• unable to be performed

• significantly delayed

  • including those requiring stabilization before transfer

• unsuccessful or associated with recurrence of massive hemorrhage

Contraindications

The presence of hemodynamic stability or the absence of a definitive endotracheal airway may be considered absolute contraindications. Relative contraindications include patients with the following ⁶:

• a history of gastric bypass surgery

• recent surgery involving the gastro-esophageal junction

• esophageal stricture

• non-variceal etiology suspected

  • etiologies of refractory non-variceal upper gastrointestinal hemorrhage in which balloon tamponade has been successfully used include:

    • erosive esophagitis ²

    • Mallory Weiss tear

    • laparoscopic adjustable gastric band erosion ⁸

Radiographic features

Portable chest radiography is the most commonly used method of confirming appropriate placement of the balloon tamponade device to ensure the gastric balloon is beyond the gastro-esophageal junction prior to full inflation. 

Plain radiograph

After full insertion of the device, typically to an empiric depth of 50 cm, a chest radiograph should demonstrate the tube descent along the expected course of the esophagus with the distal tip terminating below the level of the left hemidiaphragm ⁷. Partial inflation of the gastric balloon (typically performed with 50 mL of air) should subsequently demonstrate the appearance of a lucent, circular structure below the diaphragm and corresponding to the expected location of the gastric body; a supradiaphragmatic location or migration of this lucency is concerning for intrathoracic (esophageal) malposition. 

Ultrasound

Point of care ultrasound has been used as an adjunct to radiography in determining the course and appropriate placement of the distal (gastric) balloon during the placement of balloon tamponade devices. 

Visualization usually entails obtaining a view of the gastric lumen, which may be obtained from an epigastric or left lateral (mid axillary, coronal left upper quadrant) window, and/or the gastro-esophageal junction, visualized from the epigastrium using the liver as a sonographic window . 

When visualized in its long axis the device will appear as paired, parallel hyperechoic lines. Visualization of the gastro-esophageal junction should demonstrate this tubular echogenic traversing it, extending to the gastric body. Dynamic visualization while advancing the tube may result in agitation of gastric contents; air may be injected into the gastric aspiration port to enhance the detection of this phenomenon.

After well seated in the gastric lumen, inflation of the gastric balloon may also be dynamically monitored, with balloon inflation yielding the appearance of an enlarging echogenic, semicircular interface with posterior acoustic shadowing.

Complications

• aspiration pneumonia

• tracheal obstruction

• esophageal perforation

  • pneumothorax

  • empyema

• endobronchial malposition

See also

• cirrhosis

  • portal hypertensive gastropathy

  • esophageal varices

  • gastric varices

• upper gastrointestinal bleeding

  • peptic ulcer disease

  • variceal bleed

  • Dieulafoy lesion

  • gastric antral vascular ectasia