In 1930, Westphal described the use of an esophageal sound as a means of controlling variceal hemorrhage. In 1947, successful control of hemorrhage by balloon tamponade was achieved by attaching an inflatable latex bag to the end of a Miller–Abbot tube. In 1949, a two-balloon tube was described by Patton and Johnson. A triple-lumen tube with gastric and esophageal balloons, as well as a port for gastric aspiration, was described by Sengstaken and Blakemore in 1950. In 1955, Linton and Nachlas engineered a tube with a larger gastric balloon capable of compressing the submucosal veins in the cardia, thereby minimizing flow to the esophageal veins, with suction ports above and below the balloon. The Minnesota tube was described in 1968 as a modification of the Sengstaken–Blakemore tube, incorporating the esophageal suction port, which will be described later. Several studies have published combined experience with tubes such as the Linton–Nachlas tube; however, the techniques described here are limited to the use of the Minnesota and Sengstaken–Blakemore tubes.

Treatment of portal hypertension to prevent variceal rupture includes primary and secondary prophylaxis. Primary prophylaxis consists of beta-blockers, band ligation, and endoscopic surveillance, whereas secondary prophylaxis includes nitrates, transjugular intrahepatic portosystemic shunt (TIPS), and surgical shunt [3]. Management of acute variceal bleeding involves multiple simultaneous and sequential modalities. Balloon tamponade is considered a temporary bridge within these modalities. Self-expanding metal stents as an alternative to balloon tamponade are currently under investigation [4].

Splanchnic vasoconstrictors such as somatostatin, octreotide, terlipressin (the only agent shown to decrease mortality), or vasopressin (with nitrates to reduce cardiac side effects) decrease portal blood flow and pressure, and should be administered as soon as possible [5,6,7]. In fact, Pourriat et al. [8] advocate administration of octreotide by emergency medical personnel before patient transfer to the hospital. Recombinant activated factor VII has been reported to achieve hemostasis in bleeding esophageal varices unresponsive to standard treatment, and may also be considered [9]. Emergent therapeutic endoscopy in conjunction with pharmacotherapy is more effective than pharmacotherapy alone and is also performed as soon as possible. Band ligation has a lower rate of rebleeding and complications when compared with sclerotherapy, and should be performed preferentially, provided visualization is adequate to ligate varices successfully [3,10]. Tissue adhesives such as polidocanol and cyanoacrylate delivered through an endoscope are being used and studied outside the United States.

Balloon tamponade is performed to control massive variceal hemorrhage, with the hope that band ligation or sclerotherapy and secondary prophylaxis will then be possible (Fig. 15.1). If bleeding continues beyond these measures, TIPS [11] is considered. Shunt surgery [12] may be considered if TIPS is contraindicated. Other alternatives include percutaneous transhepatic embolization, emergent esophageal transection with stapling [13], esophagogastric devascularization with esophageal transection and splenectomy, and hepatic transplantation. If gastric varices are noted, therapeutic options include endoscopic administration of the tissue adhesive cyanoacrylate, TIPS, balloon-occluded retrograde transvenous obliteration [14], balloon-occluded endoscopic injection therapy [15], and devascularization with splenectomy, shunt surgery, and liver transplantation.

A Minnesota or Sengstaken–Blakemore tube is indicated in patients with a diagnosis of esophageal variceal hemorrhage, in which neither band ligation nor sclerotherapy is technically possible, readily available, or has failed [16]. If at all possible, making an adequate anatomic diagnosis is critical
before any of these balloon tubes are inserted. Severe upper gastrointestinal bleeding attributed to esophageal varices in patients with clinical evidence of chronic liver disease results from other causes in up to 40% of cases. The observation of a white nipple sign (platelet plug) is indicative of a recent variceal bleed. A balloon tube is contraindicated in patients with recent esophageal surgery or esophageal stricture [17]. Some authors do not recommend balloon tamponade when a hiatal hernia is present, but there are reports of successful hemorrhage control in some of these patients [18]. If there is no other option, it may be practical to titrate to the lowest effective balloon pressures especially if repeated endoscopic sclerotherapy has been performed as there is increased risk of esophageal perforation [19].