Balloon Tamponade of Gastroesophageal Varices

• The main indication for placement of a GEBT tube is a patient with known portal hypertension or prior variceal hemorrhage who has severe upper GI bleeding that does not clear with gastric lavage and pharmacologic therapy.
• When endoscopy is available, the indication for a GEBT tube is ongoing variceal hemorrhage that cannot be controlled with endoscopic interventions.
• A nasogastric (NG) tube should be placed in all patients with significant GI bleeding.
• IV octreotide and somatostatin are alternative treatment options.

• Lack of clear indications for use
• Lack of clinical experience with GEBT tubes
• Definitive treatment is immediately available.

• GEBT tube
• Traction device or setup, including weights
• Manual manometer or sphygmomanometer
• Y-tube connector (if not already built into the tamponade balloon ports)
• Vacuum suction device, tubing, and connectors
• Soft restraints
• Topical anesthetic (spray and jelly) and water-soluble lubricating jelly
• 3 or 4 tube clamps
• Large (e.g., 50 mL) catheter tip irrigating syringe
• Surgical scissors for emergency balloon decompression
• Standard NG tube (may not be required if GEBT has a built-in gastric aspiration port)

• Venous drainage from the stomach is into the left and right gastroepiploic veins, which drain into the portal vein via the splenic vein and superior mesenteric vein, respectively.
• Below the level of the superior vena cava, venous drainage from the esophagus is into the azygos and accessory hemiazygos veins.
• The distal esophagus also has venous drainage into the esophageal branches of the coronary vein, which form a plexus that drains into the portal vein.
• Increased portal vein pressure causes dilation of the coronary vein and the associated submucosal plexus in the distal esophagus. This produces thin-walled varices just below the mucosa in the esophagus and stomach that are at risk for rupture.

• After bleeding has been controlled for several hours, reduce the pressure in the esophageal balloon by 5 mm Hg every 3 hours (or as specified in product instructions), until an intraesophageal balloon pressure of 25 mm Hg (or as specified in instructions) is achieved without ongoing bleeding.
• If bleeding can be controlled with an intraesophageal balloon pressure of 25 mm Hg, maintain this pressure for the next 12 to 24 hours.
• Once satisfactory positioning of the GEBT tube has been confirmed, do not disturb the tube for 20 to 24 hours, unless necessary because of complications.
• Provide the patient with analgesics and sedation.
• Apply soft restraints to the patient’s arms.
• If the bleeding does not remain controlled, other therapeutic interventions must be considered.

• Complications associated with the use of GEBT tubes are frequent and often very serious.
• Aspiration pneumonitis
• Asphyxia due to airway obstruction has been reported to occur with dislodgment of the tube such that the esophageal balloon migrates into the oropharynx. Keep scissors at the bedside so that the tube can be cut and quickly removed if this complication occurs.
• Esophageal perforation or rupture
• Uncommon major complications include duodenal rupture, tracheobronchial rupture, and periesophageal abscess formation.
• Common minor complications include pain, discomfort, local pressure effects of gastric or esophageal erosions or mucosal ulcers, regurgitation, chest discomfort, back pain, and pressure necrosis of the nose or lip.

It is not uncommon for the GEBT tube to fail to control the hemorrhage. When significant bleeding continues, consider correctable causes. When these have been addressed but bleeding continues, other therapeutic options must be considered.