Esophageal Rupture Due to Unexpected Sengstaken-Blakemore Tube Placement

A 70-year-old Japanese man was hospitalized with type C cirrhosis. Following endoscopic variceal ligation (EVL) for esophageal varices (EV), esophagogastroduodenoscopy (EGD) was confirmed with multiple vascular telangiectasia and esophageal scars. The patient was admitted with massive hematemesis and underwent an emergency EGD, which revealed EV bleeding. The endoscopic hemostasis procedures performed were not effective.

Although a Sengstaken-Blakemore (SB) tube placement was required for hemostasis, the patient complained of severe chest discomfort immediately after air injection for the gastric balloon following SB tube insertion and auscultation confirmation. Computed tomography showed mediastinal and subcutaneous emphysema. The SB tube position was immediately changed by EGD without air suffusion for drainage with its tip in proximity to the lower sphincter. This revealed extensive lower esophagus perforation (Fig. 1A). The patient underwent fasting and antibiotics administration. EGD performed 15 days after the perforation revealed that the hole had decreased in size and improved (Fig. 1B), and the patient was on a good clinical course. He was then discharged from the hospital.

FIG. 1. Esophagogastroduodenoscopy (EGD) confirmed extensive perforation of the lower esophagus due to a Sengstaken-Blakemore tube misplacement with air inflation of a gastric balloon (A). EGD performed 15 days after the perforation showed that the size of the perforation hole had decreased and improved (B).

While the balloon tamponade with the SB tube is life-saving and effective in 50-90% of EV bleeding cases, the SB tube usage decreased steadily due to the high incidence of complications. The esophageal perforation rate due to SB tubes is 2-10%.1 It is important to consider this possibility in any patient presenting with unanticipated chest or abdominal pain after SB tube insertion. In our case, when the SB tube approached the distal esophagus, kinking easily occurred in the process because of the multiple EVL scars and the lower sphincter. The soft tube material allows for easier kinking in the stomach direction. This placement is then followed by gastric balloon inflation. A secondary recognition (X-ray, sonography guidance, or direct visualization with endoscopy) is then used in addition to auscultation to confirm the tube’s position.