Sengstaken-Blakemore Tube: A Lifesaving Intervention in Acute Upper Gastrointestinal Hemorrhage

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 Sengstaken-Blakemore Tube: A Lifesaving Intervention in Acute Upper Gastrointestinal Hemorrhage


Figure 1. Fluoroscopic image showing correctly placed Sengstaken-Blakemore tube with gastric and esophageal balloons inflated.


Introduction

The Sengstaken-Blakemore tube (SBT) remains a critical tool in the management of life-threatening esophageal variceal hemorrhage, particularly in settings where endoscopic hemostasis or transjugular intrahepatic portosystemic shunt (TIPS) are not immediately available. First introduced in the 1950s, this balloon tamponade device has proven its value in emergent hemostasis for patients with portal hypertension-induced variceal bleeding.

In this expert column, we will explore the indications, technique, complications, imaging role, and clinical pearls associated with Sengstaken-Blakemore tube placement, based on real-world radiologic case data.

What Is the Sengstaken-Blakemore Tube?

The Sengstaken-Blakemore tube is a triple-lumen device designed to temporarily tamponade bleeding esophageal varices. It comprises:

  • Gastric balloon for anchoring

  • Esophageal balloon for variceal compression

  • Gastric aspiration port for decompression and monitoring bleeding

Modern variants include the Minnesota tube, which adds an esophageal suction port.

Clinical Indications

  • Massive upper GI hemorrhage from esophageal or gastric varices

  • Failed endoscopic therapy or unavailable resources

  • Temporizing measure before definitive intervention (e.g., TIPS)

Contraindications include:

  • Suspected esophageal rupture (Boerhaave's)

  • Severe coagulopathy without correction

  • Unconscious patients without airway protection

Radiological Role in SBT Placement

While blind insertion is possible, fluoroscopy-guided placement significantly enhances safety and confirms correct positioning. The radiologist plays a key role in:

  • Confirming the gastric balloon in the stomach (preventing esophageal perforation)

  • Evaluating for tube migration or leakage

  • Monitoring the inflation of balloons under direct visualization

Case Summary: Fluoroscopic Placement

A 58-year-old male with decompensated cirrhosis and hematemesis underwent SBT insertion. Due to active bleeding and hemodynamic instability, endoscopy was deferred.

Procedure:

  • The tube was inserted nasally and advanced into the stomach.

  • A contrast injection confirmed intragastric placement.

  • The gastric balloon was inflated with 200 mL of air under fluoroscopy.

  • After gentle traction, the esophageal balloon was inflated with 50 mL.

  • Hemostasis was achieved, and the patient was transferred to the ICU.

[Figure 1] shows the final tube position with inflated balloons visualized under fluoroscopy.


Clinical Technique: Step-by-Step Guide

  1. Patient intubation and sedation: Ensures airway protection.

  2. Lubricated tube insertion: Through the mouth or nose.

  3. Balloon inflation under imaging:

    • Gastric balloon: 200–250 mL of air.

    • Confirm position with fluoroscopy or X-ray.

  4. Apply traction: Secure tube to maintain tension.

  5. Inflate esophageal balloon (if needed): 30–50 mmHg max pressure.

  6. Monitor patient: Vital signs, bleeding control, and signs of complications.

Potential Complications

Despite its efficacy, the SBT can lead to serious adverse events:

ComplicationDescription
Esophageal perforation      Especially with overinflation or malposition
Mucosal ulceration      Due to prolonged balloon pressure
Aspiration pneumonia      If the airway is not secured
Tube migration      They can block the airway if not fixed properly

Thus, maximum inflation times (usually <24 hours) and frequent monitoring are essential.

Comparative Efficacy and Modern Alternatives

While effective, the SBT has largely been replaced by:

  • Endoscopic variceal ligation (EVL)

  • TIPS placement

  • Balloon-occluded retrograde transvenous obliteration (BRTO)

Still, the Sengstaken-Blakemore tube remains invaluable in unstable patients or in resource-limited settings.

Best Practices & Clinical Pearls

  • Always intubate before insertion to prevent aspiration.

  • Use imaging confirmation to avoid misplacement.

  • Do not exceed recommended pressures: gastric balloon (~250 mL air), esophageal balloon (<50 mmHg).

  • Document balloon inflation volumes and durations.

  • Use nasogastric suction to monitor ongoing bleeding.

Conclusion

The Sengstaken-Blakemore tube is a time-tested, lifesaving measure in massive upper gastrointestinal bleeding, especially from esophageal varices. While superseded by more definitive therapies in many settings, it remains an indispensable part of the acute GI hemorrhage management toolkit. Proper technique, radiologic support, and vigilant monitoring are key to maximizing outcomes and minimizing risks.

References

[1] T. R. De Franchis, "Updating consensus in portal hypertension: Report of the Baveno VI Consensus Workshop," J. Hepatol., vol. 63, no. 3, pp. 743–752, Sep. 2015.

[2] A. Garcia-Tsao and J. Sanyal, "Management and prevention of variceal hemorrhage in cirrhosis," N. Engl. J. Med., vol. 362, no. 9, pp. 823–832, 2010.

[3] J. Krige and J. Thomson, "Endoscopic and radiologic management of variceal bleeding," HPB, vol. 10, no. 6, pp. 432–438, 2008.

[4] G. P. Bosch et al., "Portal hypertension and variceal bleeding," Clin. Liver Dis., vol. 14, no. 2, pp. 281–295, 2010.

[5] J. Biecker, "Diagnosis and therapy of esophageal varices," World J. Gastroenterol., vol. 17, no. 31, pp. 3474–3479, 2011.

[6] L. Sarin et al., "The role of Sengstaken-Blakemore tube in current practice," World J. Emerg. Med., vol. 5, no. 1, pp. 74–77, 2014.

[7] J. M. Caldwell et al., "Rescue balloon tamponade in gastrointestinal hemorrhage: Still relevant?," Emerg. Med. J., vol. 37, no. 7, pp. 428–432, 2020.

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