Placement confirmation of Sengstaken–Blakemore tube by ultrasound

The management of oesophageal bleeding disorders remains a challenging problem in the emergency department. Oesophageal varices are dilated veins; they are most commonly a result of portal hypertension and are often associated with a poor outcome.¹ Haemorrhage from oesophageal varices is a life‐threatening emergency with a mortality rate of 30–50%. Approximately 90% of patients with cirrhosis will develop varices, of which bleeding occurs in 25–35%.² Balloon tamponade is one of the methods for temporary control of acute variceal haemorrhage and works by directly compressing the varices at the bleeding site. Placement of a Sengstaken–Blakemore tube into the gastric fundus controls variceal bleeding via a tamponading effect. However, incorrect placement of the tube with inflation of the balloon in the oesophagus may cause oesophageal perforation or extrinsic compression of the trachea.³ The Sengstaken–Blakemore tube can be placed nasogastrically or orogastrically and maintained in the correct position as confirmed by chest radiograph. Traditionally, the tube is first presumed to be placed in the stomach, then the gastric balloon is partially inflated with 50 cc of either water or air. A chest x ray is required to confirm the position of the gastric balloon in the stomach before it can be fully inflated. However, the partially inflated balloon is not always visualised on chest x ray. Other methods for placing the Sengstaken–Blakemore tube utilising endoscopic confirmation have been reported.⁴ However, endoscopic confirmation is not readily available in all clinical areas, and there may be undue delay in placing the Sengstaken–Blakemore tube if it is recommended for all procedures. We describe an easy‐to‐use method with ultrasound that is readily available in every emergency setting for Sengstaken–Blakemore tube placement confirmation.

For ultrasound confirmed placement of the Sengstaken–Blakemore tube, it is inserted and the patient is placed in a supine position. The transducer is placed sagittally along the midline of the epigastrium and then tilted toward the patient's left to identify the gastroesophageal junction. With the gastroesophageal junction in view, the ultrasound probe is rotated counterclockwise to best see the liver, aorta and lower oesophageal sphincter. This view confirms the presence of the tube traversing through the lower oesophagus sphincter into the stomach (fig 1). However, failure in identifying the gastroesophageal junction due to a poor echo window sometimes occurs, especially in those with massive ascites and/or obesity. Because patients who require gastroesophageal tamponade for active variceal haemorrhage are almost always hemodynamically unstable, delay in inflating the balloon may have serious consequences. The use of ultrasound in this emergency setting obviates the need for a possibly equivocal radiograph confirmation and can improve patient care. The proficiency of emergency department physicians in performing ultrasound examinations should be enhanced.

Figure 1 The liver, aorta and lower oesophagus sphincter (arrow) are seen and the image represents the passage of the Sengstaken–Blakemore tube through the lower oesophagus sphincter into the stomach.