Balloon tamponade for bleeding varices

What it is

Balloon tamponade is a temporary rescue for massive bleeding from oesophageal or gastric varices that cannot be controlled by drugs and endoscopy, or when endoscopy is not available. The Sengstaken–Blakemore tube has three channels: a gastric balloon, an oesophageal balloon and a gastric aspiration port; the Minnesota tube adds an oesophageal aspiration port above the balloon, and the Linton–Nachlas tube has a single large gastric balloon for gastric varices. Most bleeding stops with the gastric balloon alone, inflated in the stomach and pulled up against the gastro-oesophageal junction, which compresses the inflow to the varices; the oesophageal balloon is inflated, with a manometer, only if bleeding continues. Tamponade controls bleeding in most patients, but bleeding returns in many when the balloons go down, so it is only a bridge, kept for no more than about a day, to endoscopic band ligation or a transjugular intrahepatic portosystemic shunt (TIPS). Because the patient is usually vomiting blood and drowsy, the airway is secured with intubation first. Vasoactive drugs, antibiotic prophylaxis and careful transfusion continue alongside.

Indications

• Massive oesophageal or gastric variceal bleeding not controlled by vasoactive drugs and endoscopic therapy.
• Haemodynamic instability from variceal bleeding when endoscopy is not available or is delayed.
• Bridge to transfer, repeat endoscopy or TIPS.
• Bleeding that recurs early after endoscopic treatment while definitive therapy is arranged.

Contraindications and precautions

• Airway not protected: intubate first; aspiration is a leading cause of death.
• Recent oesophageal or gastric surgery, or a known oesophageal stricture: risk of perforation.
• Bleeding source not likely variceal: tamponade does not help ulcers or tears, and may harm.
• Prolonged inflation of the oesophageal balloon causes ischaemia and necrosis: limit the time and deflate as protocol sets.
• Requires an experienced team and an intensive-care setting with continuous observation.

Equipment

• Sengstaken–Blakemore, Minnesota or Linton–Nachlas tube, checked for leaks before use.
• Syringe for air, clamps and a manometer for the oesophageal balloon pressure.
• Water-soluble lubricant, suction and a nasogastric tube if the tube has no oesophageal port.
• Traction system or fixation as the unit protocol sets, and scissors kept at the bedside.
• Equipment for intubation and a portable X-ray.

Step by step (and why)

1. Intubate and start vasoactive drugs, antibiotics and transfusion — airway and circulation come before the tube.
2. Test both balloons for leaks under water, then deflate fully — a leaking balloon fails when it is needed.
3. Lubricate and pass the tube through the mouth well into the stomach — insertion too short leaves the balloon in the oesophagus.
4. Aspirate the gastric port and inflate the gastric balloon with a little air, then X-ray — it proves the balloon is below the diaphragm.
5. Complete gastric inflation as the device specifies and clamp it — a full balloon anchors at the junction.
6. Pull back gently until resistance and apply steady traction — the balloon presses on the inflow to the varices.
7. If bleeding continues, inflate the oesophageal balloon to the target pressure on a manometer — measured pressure limits necrosis.
8. Mark the tube at the mouth, aspirate both ports regularly — a moved mark warns of migration; aspirate shows rebleeding.
9. Plan release within about a day and arrange endoscopy or TIPS — the balloon only buys time.

The tubes and their channels

Complications

• Aspiration pneumonia, the most common serious complication.
• Oesophageal ulceration, necrosis or rupture, especially with high or prolonged oesophageal balloon pressure.
• Airway obstruction if the gastric balloon deflates or migrates up into the pharynx.
• Rebleeding when the balloons are deflated, in a large share of patients.
• Chest pain, arrhythmias and discomfort; tube displacement.

Next step

• Arrange definitive treatment (band ligation or TIPS) while the tube controls bleeding: involve gastroenterology and interventional radiology early.
• Deflate the oesophageal balloon first, then the gastric balloon, and watch for rebleeding before removal.
• Watch for sudden respiratory distress: cut and remove the tube if the balloon has migrated.
• Continue vasoactive drugs and antibiotic prophylaxis, and correct coagulopathy as the unit decides.
• After recovery, plan secondary prophylaxis (repeat banding and a non-selective beta-blocker) and treat the liver disease.

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Elsewhere in DurgiPedia

• Upper and lower gastrointestinal bleeding
• Blood transfusion: bedside checks, monitoring and reactions

Connections

← All clinical skills

Educational content; it does not replace supervised hands-on training, your institution's protocols or a prescriber's order. A procedure is learnt with a teacher and done only once you are trained to do it.

Sources: Sengstaken-Blakemore Tube (StatPearls (NCBI Bookshelf), 2025); Esophageal Varices (StatPearls (NCBI Bookshelf), 2026).

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Representative model, for educational purposes only.