Sengstaken-Blakemore Tube

Anatomy and Physiology

Esophageal varices are a direct manifestation of chronic portal hypertension, which most commonly results from cirrhosis. Progressive fibrosis, architectural distortion, and regenerative nodules obstruct normal portal venous outflow in the cirrhotic liver. This resistance elevates pressure within the portal system, diverting blood through collateral pathways connecting the portal and systemic circulations.[7] One of the most clinically significant networks involves the left gastric vein (coronary vein), which drains into the portal vein and communicates with the esophageal venous plexus. These submucosal and paraesophageal veins further connect with the systemic azygos and hemiazygos veins, forming fragile, thin-walled varices in the distal esophagus and proximal stomach.[8]

The risk of variceal rupture increases with portal pressure, variceal size, wall tension, and acute triggers such as vomiting, retching, or elevated intraabdominal pressure. Bleeding is often brisk and life-threatening when rupture occurs. The Sengstaken-Blakemore tube achieves hemostasis by applying direct mechanical pressure against the mucosa overlying these varices, tamponading the bleeding source. The tube includes 2 inflatable balloons, one positioned distally in the stomach and another proximally in the esophagus, each connected to an individual inflation port. The gastric balloon anchors the tube and compresses the gastroesophageal junction (GEJ), while the esophageal balloon, when required, exerts pressure within the thoracic esophagus to tamponade varices directly.

The tube also includes a gastric aspiration port, allowing decompression and monitoring of ongoing bleeding. Unlike the Minnesota tube, the Sengstaken-Blakemore tube lacks an esophageal suction port. Clinicians must insert a separate nasogastric (NGT) or orogastric (OGT) tube above the balloon to manage proximal secretions or blood pooling. This setup helps identify the bleeding source: persistent blood return through the NGT after gastric balloon inflation indicates that esophageal tamponade may be necessary. Understanding this anatomic and physiologic basis is essential for proper tube use and troubleshooting during active hemorrhage.

Indications

The Sengstaken-Blakemore tube is indicated as a rescue intervention for acute, uncontrolled upper gastrointestinal bleeding secondary to esophageal varices, particularly when standard therapies are unavailable, delayed, or unsuccessful. The primary purpose of this device is to achieve temporary hemostasis in massive variceal hemorrhage that does not respond to pharmacologic agents, such as octreotide, vasopressin, and somatostatin analogs, or endoscopic interventions, including variceal band ligation or sclerotherapy. In modern practice, the tube is most often used in emergent settings when endoscopy is not immediately available, such as when treatment occurs in rural hospitals, patients are in transit to tertiary centers, or persistent hemodynamic instability precludes immediate endoscopy.

Balloon tamponade is not considered definitive therapy, but it serves as a bridge to more durable interventions, such as repeat endoscopic therapy or TIPS. The procedure should be completed within 24 hours to minimize the risk of serious complications.[9] Early consultation with gastroenterology, interventional radiology, and critical care specialists is strongly recommended to facilitate definitive treatment.

Both the American Association for the Study of Liver Diseases and the European Association for the Study of the Liver include balloon tamponade as a salvage measure in their practice guidelines. These societies emphasize that all patients with suspected variceal hemorrhage should receive volume resuscitation, vasoactive drugs, early antibiotic prophylaxis, and timely endoscopic evaluation. When endoscopy fails or is delayed, balloon tamponade may be deployed by trained providers in coordination with the interprofessional team to stabilize patients and prevent exsanguination.[10]

Contraindications

Sengstaken-Blakemore tube insertion has no absolute contraindications when used to manage massive variceal hemorrhage urgently. In cases of profound hemodynamic instability or uncontrolled bleeding, the urgency of achieving hemostasis outweighs most procedural concerns. However, several relative contraindications should be considered, particularly when alternative methods of hemorrhage control are available, and time permits interprofessional consultation. These conditions include the following:

• Known esophageal strictures or stenosis
• Recent upper gastrointestinal or esophageal surgery
• Large or complicated hiatal hernias
• Unresolved severe coagulopathy
• Active esophageal ulceration or mucosal disruption
• Recent endoscopic variceal interventions (eg, band ligation or sclerotherapy within the preceding 7-10 days) [11][12]

These circumstances increase the risk of complications such as mucosal injury, tube misplacement, esophageal necrosis, and perforation. Balloon tamponade may still be justified in emergent situations where bleeding is ongoing, and other methods are not immediately feasible. The potential benefit of hemorrhage control often outweighs the procedural risk, especially when performed by trained personnel with airway protection and continuous monitoring.

Prior to placement, a risk-benefit discussion should occur among members of the interprofessional team, including critical care physicians, gastroenterologists, and nursing staff. Whenever feasible, imaging or prior endoscopic reports may help identify structural contraindications. Appropriate preparation, including intubation, hemodynamic stabilization, and full procedural setup, should always be completed before attempting placement. Nonetheless, Sengstaken-Blakemore tube insertion remains a time-sensitive, life-saving measure, and its use should not be withheld solely due to relative contraindications if bleeding is uncontrolled.[13]

Equipment

Successful placement of a Sengstaken-Blakemore tube requires thorough preparation and access to specific equipment. Since the procedure is typically performed under urgent conditions, having a preassembled kit or checklist can reduce delays and improve procedural safety. All materials should be organized and tested before insertion to ensure functional integrity, particularly the balloon components.

Essential equipment includes the following:

• Sengstaken-Blakemore tube (dual-balloon design)
• Double-lumen NGT or OGT for concurrent aspiration
• 60 mL luer-lock syringe for gastric balloon inflation
• 60 mL slip-tip syringe for esophageal balloon inflation
• 2 male Christmas tree luer-lock adapters
• A pair of 3-way stopcocks for pressure control and balloon management
• 4 dual luer-lock caps for port sealing
• Marking pen for labeling depth and position markers
• Sterile lubricating jelly
• Insufflation manometer to monitor esophageal balloon pressure
• Roller bandage or umbilical tape for anchoring and applying traction
• 1,000-mL intravenous fluid bag (or equivalent weight) to provide measured downward tension
• Basin of sterile water for leak testing and confirming balloon expansion prior to insertion
• Optional: Kelly clamp padded with tape to secure tubing during setup or transport

Each balloon should be tested for leaks by inflating underwater and then fully deflating before lubrication. Connectors and stopcocks should be clearly labeled and set up for rapid inflation and monitoring. Maintaining an easily accessible, prestocked “tamponade kit” helps ensure a timely and coordinated response during emergencies in facilities where balloon tamponade is rarely performed.

Preparation

Preparation for Sengstaken-Blakemore tube placement begins with securing the patient’s airway. Endotracheal intubation is mandatory due to the high risk of aspiration, airway obstruction, and active hematemesis during the procedure. Most patients are already hemodynamically unstable and require critical care support. Airway control ensures adequate oxygenation and minimizes the risk of aspiration pneumonia or hypoxic injury throughout tube placement.

Once intubated, the patient should be positioned supine with the head of the bed elevated to 30° to 45° to reduce aspiration risk and facilitate procedural access. For patients with spinal precautions or intolerance to supine elevation, the left lateral decubitus position may serve as an alternative.

After positioning, all necessary equipment should be verified and assembled. Three-way stopcocks should be attached to both the gastric and esophageal inflation ports. Prior to insertion, both balloons must be tested for leaks by inflating each underwater to confirm structural integrity. The balloons should be fully deflated if no bubbles are observed, and a generous amount of water-soluble lubricant should be applied to the tube.

To assist with placement and positioning verification, a separate double-lumen NGT or OGT should be aligned alongside the Sengstaken-Blakemore tube. The 50-cm reference line on the tamponade tube may be used as a guide to mark the NGT at 2 points: 2 cm above the gastric balloon, labeled “G” for gastric, and 2 cm above the esophageal balloon, labeled “E” for esophagus.[14] These markings facilitate postinsertion positioning of the NGT, allowing assessment of the bleeding source and determination of whether esophageal tamponade is required.

Suction systems should be prepared in advance for both gastric decompression and oropharyngeal clearance. The insufflation manometer should be connected to the esophageal balloon port and zeroed to ambient pressure. A preprocedure timeout should be conducted, and sedation planning and interprofessional team role assignment should be completed before insertion to maximize safety and procedural efficiency.

Technique or Treatment

The Sengstaken-Blakemore tube should be inserted with the patient intubated and all equipment prepared in advance. The purpose of this device is to tamponade actively bleeding esophageal or gastric varices through balloon inflation and applied traction, providing temporary hemostasis while definitive therapy is arranged.

The following steps outline the proper technique for Sengstaken-Blakemore tube insertion, positioning, and monitoring to achieve effective tamponade of esophageal or gastric varices while minimizing complications:

• Insertion: The deflated Sengstaken-Blakemore tube should be thoroughly lubricated. The apparatus should be advanced orally (or nasally if necessary) to the 50-cm mark, ensuring that the gastric balloon is positioned in the stomach beyond the GEJ. Forceful advancement should be avoided. Resistance to the device and patient response should be continuously monitored.

• Confirmation of gastric position: Placement should be verified by injecting air through the gastric port while auscultating over the epigastrium. Radiographic confirmation using chest or KUB (kidneys, ureters, bladder) x-ray or bedside epigastric ultrasound is recommended before balloon inflation to prevent esophageal rupture from misplacement.[15]

• Gastric balloon inflation: The gastric balloon should initially be inflated with 50 mL of air. Once placement is confirmed radiographically, inflation should be continued to a total of 250 to 300 mL, according to manufacturer guidelines and patient anatomy. The inflation port should be clamped or capped after full inflation.

• Applying traction: Traction should be secured by attaching a roller bandage or umbilical tape to the tube and suspending a 1,000-mL intravenous fluid bag to apply approximately 1 kg of downward force. The balloon should be positioned against the GEJ, and the tube’s position should be marked at the lips or nares with frequent monitoring for migration.

• Gastric aspiration and irrigation: Continuous suction should be initiated via the gastric port. Periodic irrigation with sterile saline should be performed to assess ongoing bleeding distal to the balloon.

• Proximal suction via NGT: An NGT should be inserted alongside the Sengstaken-Blakemore tube to the “G” mark, approximately 2 cm above the gastric balloon. Suction should be applied to evaluate for continued bleeding above the gastric balloon. Esophageal balloon inflation should be initiated if bleeding persists.

• Esophageal balloon inflation: The NGT should be advanced to the “E” mark, 2 cm above the esophageal balloon, and monitored via the insufflation manometer. The esophageal balloon should be inflated to 30 mm Hg with air. Pressure may be cautiously increased in 5-mm-Hg increments, up to a maximum of 45 mm Hg, if bleeding continues. Continuous pressure monitoring is essential, and inflation should never exceed 45 mm Hg to avoid esophageal necrosis or perforation.

• Duration and pressure monitoring: The esophageal balloon should be deflated intermittently, every 6 to 8 hours, and should not remain inflated longer than 24 hours to minimize the risk of pressure-induced ischemia and mucosal necrosis.

Additional measures include ensuring that all ports are securely closed and clearly labeled. Adequate sedation and analgesia should be provided to minimize patient discomfort and reduce the risk of accidental tube dislodgement. The respiratory therapy team should manage airway protection and ventilatory support. Early coordination with gastroenterology and interventional radiology is essential to facilitate a timely transition to definitive care, such as endoscopy or TIPS. Bedside teams are responsible for documenting timing, balloon pressures, tube position, and patient response at regular intervals to ensure safe and effective management.

Complications

Sengstaken-Blakemore tube insertion is a high-risk intervention that must be performed only by trained providers using meticulous technique and continuous monitoring. Complications are classified as minor, major, or catastrophic based on severity and clinical consequence.

Minor complications include nasal or pharyngeal mucosal irritation. Epistaxis may occur when the tube is inserted nasally. Pharyngeal discomfort or hoarseness may develop. Nasal bridge pressure ulcers can arise from prolonged use.

Major sequelae may include esophageal rupture, reported in up to 6% of cases, particularly with overinflation or malpositioning of the esophageal balloon. Esophageal necrosis may result from sustained pressure exceeding mucosal perfusion thresholds. Aspiration pneumonia can occur, especially if the airway is not protected before insertion. Balloon migration may lead to loss of tamponade or airway compromise. Airway obstruction can arise due to proximal balloon displacement or overinflation.[16][17]

Catastrophic posttreatment events may include massive gastrointestinal hemorrhage following balloon dislodgement or rupture. Tracheal compression or complete airway obstruction can occur and may be fatal if unrecognized. Tracheoesophageal or aortoesophageal fistula may develop, resulting in massive bleeding or sepsis. Cardiopulmonary arrest can arise from hypoxia, vagal stimulation, or exsanguination.[18]

Mitigation strategies include securing the airway with endotracheal intubation prior to placement. Esophageal balloon pressures should be continuously monitored with a manometer, and pressures above 45 mm Hg must be avoided. The gastric balloon should be inflated under radiographic guidance to confirm correct positioning. Esophageal balloon inflation should be limited to no more than 24 hours, with periodic deflation every 6 to 8 hours. Close interprofessional monitoring of vital signs, oxygenation, tube position, bleeding, and patient comfort is essential. Readiness for emergency deflation and reintubation must be ensured. Immediate deflation and escalation to surgery or interventional radiology are required if catastrophic events, such as chest pain, sudden drop in oxygen saturation, hemodynamic collapse, or massive hematemesis, are suspected.

Clinical Significance

Despite a decline in routine use, the Sengstaken-Blakemore tube remains a vital tool in emergency medicine and critical care. The device provides a lifesaving option for managing variceal hemorrhage when endoscopic therapies are unavailable or have failed. In such scenarios, immediate hemorrhage control and hemodynamic stabilization can prevent exsanguination and allow time for definitive therapy. Clinical success rates for bleeding control with balloon tamponade have been reported at 80% to 90%, although rebleeding often occurs once the balloon is deflated.[19]

Correct placement, vigilant monitoring, and timely transition to definitive treatment determine the efficacy and safety of this intervention. Utility is especially pronounced in rural hospitals, prehospital environments, disaster zones, and mass casualty incidents where endoscopic or interventional radiology resources may be inaccessible.

Simulation-based education has reinforced the importance of familiarity with the device, particularly among emergency and critical care teams who may encounter refractory variceal bleeding. High complication risk makes proficiency in both placement and monitoring essential. The Sengstaken-Blakemore tube functions not as a definitive treatment, but as an emergency bridge requiring coordinated interprofessional action and follow-up planning to maximize patient survival and recovery.

Enhancing Healthcare Team Outcomes

Successful use of the Sengstaken-Blakemore tube requires coordinated interprofessional teamwork and rapid mobilization of hospital resources. Effective management depends on collaboration among emergency physicians, intensivists, gastroenterologists, nurses, respiratory therapists, pharmacists, and radiology staff. Each discipline contributes essential expertise during the acute intervention and throughout the transition to definitive care.

Emergency physicians and intensivists direct the initial evaluation and placement, ensuring airway protection, hemodynamic stabilization, and bleeding control. Gastroenterologists provide definitive endoscopic therapy once stabilization is achieved, while interventional radiologists may perform TIPS or embolization when endoscopy is unsuccessful.

Critical care nurses monitor vital signs, manage suction systems, maintain balloon traction, and recognize early signs of complications. Responsibilities also include documenting pressures, assessing for pain or respiratory distress, and coordinating serial assessments with the bedside team. Respiratory therapists ensure oxygenation and ventilatory support, particularly in intubated patients at risk for airway compromise. Pharmacists guide the use of vasoactive medications, sedation strategies, transfusion thresholds, and coagulopathy management.

Structured protocols, simulation-based training, and preassembled equipment kits improve team readiness and minimize delays during rare, high-acuity events. Postprocedure debriefings allow teams to refine workflow, clarify roles, and strengthen performance for future cases. Institutions should maintain a shared framework regarding indications, balloon pressure limits, traction methods, and the timeline for transition to definitive therapy.

Although rarely required, Sengstaken-Blakemore tube placement remains a high-risk, high-reward intervention. Safe and effective use depends on interprofessional communication, mutual trust, and vigilant monitoring across all disciplines caring for patients with severe variceal bleeding.