Decline of the Sengstaken-Blakemore tube: A review of shifting practices in gastrointestinal hemorrhage management

Abstract

The Sengstaken-Blakemore tube (SB tube), introduced in the 1950s, was a pivotal device for managing acute gastrointestinal (GI) bleeding, particularly from esophageal varices. This multi-lumen tube, featuring esophageal and gastric balloons, applied mechanical pressure to control bleeding and provided a temporary solution until more definitive treatments could be employed. It was historically significant in resource-limited settings where advanced endoscopic options were unavailable, enabling patient stabilization and transfer to specialized centers. However, the advent of GI endoscopy and its increased availability has rendered the SB tube obsolete. SB tubes are associated with complications, including esophageal perforation, aspiration pneumonia, and gastric ulceration. Additionally, the tube can cause significant discomfort, and its migration may lead to inadequate. Techniques such as endoscopic variceal ligation and endoscopic sclerotherapy offer superior precision, efficacy, and safety for managing variceal bleeding. Improved hospital transfer protocols now facilitate prompt endoscopic or surgical interventions, reducing the need for temporary measures like the SB tube. Additionally, advancements in pharmacological treatments, including vasoactive drugs, reliance on mechanical compression devices. While the SB tube remains an important historical artifact, its role in current medical practice reflecting safer and more effective treatment options in emergency GI care. This review discusses the declining role of the Sengstaken -Blakemore tube and its replacement by current intervention methods.

Key Words: Variceal bleeding; Sengstaken-Blakemore; Decompensated cirrhosis; Esophageal varices; Balloon tamponade; Esophageal stent

Core Tip: The Sengstaken-Blakemore tube, introduced in the 1950s, was once vital in managing acute gastrointestinal (GI) bleeding, particularly from esophageal varices. Over the years, modern techniques with advanced precision, efficacy, and safety for managing variceal bleeding have emerged, causing a significant decline in its use. Today, the interplay between the introduction of GI endoscopy and enhanced pharmacological interventions render the Sengstaken-Blakemore tube obsolete in emergency GI care. The decline of the historically significant device warrants a review its replacements.

INTRODUCTION

The introduction of the Sengstaken-Blakemore tube (SB tube) began in the 1950s by Drs. Robert Sengstaken and Arthur Blakemore[1,2]. Drs. Sengstaken and Blakemore observed that patients with hepatic cirrhosis who had esophageal varices died shortly after admission due to liver failure[1,3]. They recognized that esophageal varices hemorrhage induced by portal hypertension remained a significant cause of mortality[3]. The Sengstaken-Blakemore design was influenced by portal hypertension and its effects on esophageal varices. The hepatic vein pressure gradient and portal pressures helped determine the inflation pressure required to compress the coronary-esophageal collateral circuit veins. They also derived the pressure that the compressed esophagus can tolerate over extended[1,3].

Inspired by observations the lack of device readily available for esophageal varices tamponade, the SB tube was introduced to better manage esophageal varices hemorrhage and end-organ shock[3]. The invention of the SB tube served as an imperative solution decrease total blood loss and delay death when no device was available for an esophageal variceal tamponade[1]. The SB tube was a life-saving measure address procedural shortcomings faced in the 1950s and serv as one of the most stabilizing measures of their time. The SB tube, which has undergone multiple adaptations and modifications, inspire many new technologies[4,5].

MECHANISM OF ACTION AND USE

The SB tube was designed with the intent that an inflated balloon in a patient's stomach would compress the gastric vein at the coronary-esophageal junction and thus halt bleeding[3]. The tube is a single-use, non-sterile tube that is introduced orally or nasally and consists of three: Gastric balloon, esophageal balloon, and gastric suction port. The SB tube is for unstable patients in life-threatening situations with uncontrollable hemorrhage from esophageal or gastric varices[1,6]. It is also in instances where endoscopy is unavailable or when a patient with an acute bleed is unresponsive to endoscopic hemostasis and vasoconstrictor therapy[7]. temporary method to control variceal bleeding in patients until circulatory resuscitation and stabilization until endoscopy can be performed. It used patients gastric varices hemostasis cannot be easily achieved if there is a lack of advanced facilities or equipment. can be used in patients with rebleeding after esophageal variceal obliteration. This allows for planning more definitive procedures to control bleeding[1,7]. The gastric aspiration port of the SB tube can be to empty the blood residue from the stomach thus allowing for better visualization particularly patients where erythromycin or prokinetics are contraindicated. This also helps to reduce risk of aspiration, nausea and vomiting.

To yield the desired outcome, careful preparation is the key. Therefore, patients’ airways must be protected before. Before tube insertion, patients intubated, mechanically ventilated and started on IV fluid to maintain blood volume and circulation. Afterward, the patient is elevated to a 45-degree angle, and the tube is marked at 50 cm distally[1]. Often, patients are placed in the left lateral position to prevent aspiration. With the patient still at a 45-degree angle, a lubricated and fully deflated tube is inserted orally[1]. The protocol is to verify placement with X-ray confirmation, inflate the gastric balloon to a total of 200 mL - 250 mL of air, apply 1 kg of traction using a roller bandage, allow the tube to stretch slightly over 10 minutes, secure the tube, check for bleeding by performing a gastric suction rinse and repeat[1]. Bleeding persist despite gastric balloon inflation, the esophageal balloon is then inflated to 30 mmHg using a manometer[1]. Confirmation of the position of the SB tube must be using an or ultrasound correct placement[1,8]. Ortiz et al[9] describe endoscopic placement of SB tube in 10 patients. tube can be used prior to inflating the esophageal to check for bleeding and suction blood. of active bleeding suggests bleeding stopped or is likely from the gastric varices. The traditional SB tube does not have an esophageal suction port, which can lead to secretions and blood pooling in the esophagus. The Minnesota tube or modified SB tube has an additional lumen to aspirate the esophagus[4,5]. Images of SB tube and insertion techniques described in literature[10,11].

LIMITATIONS AND COMPLICATIONS

Although effective in controlling bleeding, the Sengstaken-Blakemore placement comes with significant complications and challenges for clinicians and patients. A common and frequent complication seen is aspiration during insertion. However, this risk can be minimized by emptying the stomach and lowering the endotracheal intubation threshold. Other complications include esophageal perforation due to balloon migration[6,9,10]. However, this can be corrected by following a proper technique that deflates both balloons before insertion, accurately positioning the gastric balloon, and avoiding overinflation of the esophageal balloon. Gastric ulceration is another major procedure complication caused by local pressure effects[12]. Other minor complications include pain, hiccups, and discomfort. Often, deflation of esophageal balloons every 2 hours for 10 minutes is done to prevent esophageal necrosis. Balloon inflation over 24 hours can be associated with high risk for esophageal ischemia and necrosis. SB tube is contraindicated in patients with prior gastric or esophageal surgery, esophageal or gastric ulcers, and esophageal strictures.

SB tube placement. These challenges include technical difficulty, risk of tube misplacement, and need for constant monitoring. In emergency setting with an unstable patient, technical difficulty can present during[6,13]. Improper placement can cause esophageal necrosis and even esophageal perforation as. There is also a risk of the tube inserted into the airway instead of the esophagus. This can lead to airway obstruction and life-threatening aspiration. Another challenge in application is the constant need for monitoring[6]. Close monitoring is key controlling bleeding and ensuring the balloons remain in the correct place of compromising the airway if the esophageal balloon exerts pressure on the trachea. This can lead to tracheal rupture, subcutaneous emphysema and respiratory distress[14-17].

EVOLUTION OF VARICEAL BLEEDING

Initial management of variceal bleeding includes stopping and preventing recurring bleeding and complications. Primary prophylaxis to prevent variceal bleeding is emphasized by the American Association for the Study of Liver Diseases (AASLD), the American Society for Gastrointestinal Endoscopy, and the European Society of Gastrointestinal Endoscopy guidelines[18-20]. Apart from vasoactive agents and blood transfusions (targeting a hemoglobin level of about 7 g/dL in patients without comorbidities, such as ischemic coronary disease), proton pump inhibitors, and antibiotic administration, endoscopic therapy is the definitive management for bleeding varices. Vasoactive agents include octreotide, somatostatin, and terlipressin, which. Terlipressin is the treatment if available for variceal bleeding. It acts within minutes of administration and stimulates the vasopressin -1 receptor located in the vascular smooth muscle. It increases mean arterial pressure and decreases portal flow and pressure[21]. In a randomized trial terlipressin alone had a five-day treatment failure with an odds ratio of 14.46 and increased transfusion requirement compared to endoscopic variceal ligation (EVL) plus terlipressin[22,23]. Terlipressin and vasopressin are associated with adverse effects including chest pain, bradycardia, High blood pressure, abdominal pain, diarrhea, headache and hyponatremia. Adverse eventswere noted even with terlipressin. Adverse events with octreotide were lower compared to terlipressin and include abdominal pain, hyponatremia, hyperglycemia, headache and high blood pressure[24]. In patients on both vasoactive agents and SB tube, systemic vasoconstriction from vasoactive agents can increase risk of mucosal ischemia, ulceration and necrosis from balloon inflation.

Endoscopy is recommended to be performed within 12 hours of admission after resuscitation according to AASLD guidelines[18]. EVL is the standard therapy for variceal bleeding in combination with intravenous vasoconstrictor agents. Sclerotherapy is an alternative in places where EVL is not available. Compared to sclerotherapy, EVL is safer, with lower rates of rebleeding and complications and a higher rate of variceal eradication[25]. Balloon tamponade is often used as a rescue measure for the failure of endoscopic therapy[26]. The complication rate from balloon tamponade can be as high as 40%. Complications noted include aspiration pneumonia, esophageal ulceration, esophageal perforation, failure to control bleeding or rebleeding and death[27]. It can be used for up to 24 hours, and rebleeding occur in up to 50% of the population after balloon deflation. In a study by Choi et al[28] on sixty-six consecutive patients with refractory variceal bleeding managed with an SB tube, the authors reported a rebleeding rate of 22%. The esophageal rupture occurred in 6.1% of cases. The 30-day mortality rate was 42%, particularly in patients who failed to control bleeding with SB tubes and those who were intubated before tube placement[28]. Haddock et al[29] described a 6.4% (12 patients) fatal complication rate in 126 SB tube placements. The authors also describe a recurrence of rebleeding 21%. Patients with higher scores had variceal bleeding that was difficult to control (Figure 1 and Table 1).

Figure 1 Schematic diagram of esophageal variceal band ligation and balloon tamponade.

Table 1 Outcomes of various techniques for variceal bleeding from current literature.

Classification	Percentage
Success rate by primary EVBL	87%
Success rate in balloon tamponade without rebleeding	59%
Rates of Failure to control bleeding on balloon tamponade and re-bleeding on tamponade	21%-40.9%
Death from esophageal perforation from balloon tamponade	1.2%-6.4%
TIPS attempted rates in failed balloon tamponade	24%-50%
TIPS successful rates for esophageal varices	85%-94%
BRTO successful rates for gastric varices	97.3%-100%
Cyanoacrylate glue success for gastric varices	85%
Combined cyanoacrylate glue and endoscopic ultrasound guided coiling (endo coil) for gastric varices	100%
Combined TIPS and BRTO success rated for gastric and esophageal varices	100%

EVBL: Esophageal variceal band ligation; TIPS: Transjugular intrahepatic portosystemic shunt; BRTO: Balloon-occluded retrograde transvenous variceal embolization/obliteration.

Esophageal stenting with self-expandable metal stents is an upcoming bridge therapy for variceal management[30]. It is not Food and Drug Administration-approved for use in the United States. It can achieve hemostasis with similar efficacy and improved safety compared to balloon tamponade. It can be used for up to 14 days as a bridging measure, in contrast to balloon tamponade. In a study by Rodrigues et al[31] comparing esophageal balloon tamponade and stenting, the short-term rebleeding rate was 35.5% vs 12.7%, respectively. Escorsell et al[32] conducted a randomized controlled trial comparing esophageal stent placement to balloon tamponade (13 vs 15 patients). The authors reported that the success rate of esophageal stenting was 66% compared to 20% with balloon tamponade. However, the survival difference and absence of bleeding at six weeks were not significantly different between groups. Patients in the balloon tamponade group frequently required a transjugular intrahepatic portosystemic shunt (TIPS) after intervention. Device-related side effects were present in 8% of stent placements compared to 40% in balloon tamponade[32].

Complications of esophageal stenting include stent migration, failure to control bleeding, esophageal perforation, and difficulty removing the stent. The SX-ELLA Danis stent is indicated explicitly for bleeding esophageal varices. This stent has a reduced migration risk and a clinical efficacy close to 95%-100%. The ELLA extractor can be used to remove the stent without trauma[33]. This stent is unavailable in the United States. Currently, available stents in the United States are not approved for variceal bleeding and are used off-label. In a systematic review and meta-analysis by McCarty et al[34] on 155 patients with esophageal stent placement for variceal bleeding, the success rate for controlling bleeding was 96%. Adverse events included stent migration in thirty-five patients, rebleeding within 48 hours in eleven, and ulceration in six patients, totaling a 36% complication rate. The majority of studies reviewed used the SX-ELLA stent. Fatal side effects with stent placement are fewer than those with balloon tamponade. Stent placement requires a degree of expertise and training. A follow-up endoscopy is needed to remove the stent using a specialized PEX-ELLA extractor. In most studies on the SX-ELLA stent, the majority of patients underwent TIPS after stent removal to control variceal bleeding[34]. Figure 2 and Table 2 compares esophageal stenting and balloon tamponade for refractory variceal bleeding based on current evidence in literature.

Figure 2 Schematic comparison of esophageal stent placement and balloon tamponade in the treatment of refractory variceal bleeding.

Table 2 Rate of complications in esophageal stenting vs balloon tamponade from current literature.

Classification	Percentage
Success rate	66%-96%	94%
Re-bleeding	0%-16.6%	50%
Device related ulceration	2.9%-7.7%	6.7%
Device migration	18.2%-23.8%	0%
Mortality from progressive hepatic damage and multi-organ failure	0%-38.9%	42%
TIPS performed	10.9%-46.1%	66.6%
Aspiration pneumonia or broncho aspiration	7.7%	53.3%
Esophageal rupture	0%	7.1%

TIPS: Transjugular intrahepatic portosystemic shunt.

The European Association for the Study of the Liver recommends that balloon tamponade should only be used in cases of refractory esophageal bleeding and states that stents are safer than tamponade in managing refractory esophageal variceal bleeding[35]. If balloon tamponade or esophageal stent placement fails, emergency TIPS placement should be considered early in these patients. Well-established and evidence-based guidelines, including those from AASLD, American Society for Gastrointestinal Endoscopy, and European Society of Gastrointestinal Endoscopy, provide recommendations for preventing esophageal and gastric varices[11-13]. Improved diagnostic techniques, such as hepatic vein pressure gradient measurement, early initiation of nonselective beta-blocker therapy for variceal bleeding prophylaxis, regular monitoring, and surveillance endoscopy for non-bleeding varices, are standard practices[36]. The AASLD states that the goal of therapy in patients with clinically significant portal hypertension and compensated cirrhosis is to prevent decompensation events, such as variceal bleeding[18]. They are initiated in these patients, and if there is a contraindication or failure of (up to 40%), variceal ligation is performed. Reassessment is recommended for 2-4 weeks, followed by intervals of 6 months and 12 months until variceal obliteration is achieved.

Most deaths from variceal bleeding occur in patients with Child-Pugh class C cirrhosis and model for end-stage liver disease score > 19. In cases of failed bleeding control in esophageal varices, emergent TIPS placement can be considered before removing the balloon tamponade or esophageal stent. AASLD guidelines recommend preemptive TIPS placement within 72 hours of the initial upper endoscopy, ideally within 24 hours, for patients with Child-Turcotte-Pugh class B (score > 7) or Child-Turcotte-Pugh class C (score 10-13). If TIPS is unavailable, transfer to a center with TIPS capabilities is advised[18].

Cyanoacrylate injections are recommended in patients with gastric varices as primary prophylaxis for varices. It is often augmented with endoscopic coiling and can be effective in 87%-100% of patients[37,38]. Patients with bleeding gastric varices either endoscopic cyanoacrylate injections, TIPS, or balloon-occluded retrograde transvenous variceal embolization/obliteration (BRTO) can be considered first-line options[18]. Early TIPS in active esophageal variceal bleeding is associated with 97% cessation of variceal bleeding. TIPS is more effective for bleeding esophageal varices compared to gastric varices as gastric varices bleed even at lower portal pressures. TIPS is associated with procedural adverse events including exacerbation of hepatic encephalopathy. BRTO is utilized in gastric variceal bleeding with a success rate of 97.3%. BRTO can increase the risk of bleeding from preexisting esophageal varices. The combination of BRTO and TIPS also been utilized in patients with active gastric variceal bleeding and non-bleeding esophageal varices[39]. Patients with gastric varices caused by isolated splenic vein thrombosis are recommended to be assessed for splenectomy, splenic vein stenting, or splenic artery embolization[18]. There is a lack of high-quality recent evidence in literature and randomized trials on Blakemore tube. The high-risk procedure can be considered refractory variceal bleeding patients are exsanguinating and lack access to other treatment options including TIPS procedure.

Outcomes and rends over the ears

In a national patient database analysis by Elghezewi et al[36] involving 322761 patients from 2011 to 2018, there was an increase in admissions for non-bleeding esophageal varices, while the rate of esophageal variceal bleeding remained stable over the years. Patients with bleeding varices had 1.84 times the odds of being transferred to outside hospitals[36]. However, the hospital transfer rate for variceal bleeding and associated mortality has not changed over this period. Patients are often transferred to facilities for procedures such as TIPS, which cannot be performed in smaller hospitals[40]. In another nationwide study from 2007 to 2017, the mortality rate for variceal bleeding decreased from 4.01% to 3.35% (P < 0.017)[41]. The population’s average age increased from 58 to 61 during the study period. These changes may be attributed to improvements in care; standardized treatment algorithms across the country and enhanced hospital care protocols could have contributed to the decreased mortality[41]. A multidisciplinary approach to managing patients with variceal bleeding is recommended, involving gastroenterologists, hepatologists, interventional radiologists, and critical care physicians.

CONCLUSION

Standardized management algorithms and guidelines for decompensated liver disease have led to better management of variceal bleeding and improved hospital outcomes. Refractory variceal bleeding should be anticipated, and early TIPS placement within 72 hours should be practiced. Based on current literature regarding their efficacy compared to SB tubes, further studies and clinical availability of self-expanding esophageal stents should be encouraged. Current evidence strongly supports a preventative approach for non-bleeding varices and indicates a trend toward stent placement in refractory bleeding compared to balloon tamponade.