The module covers:

1. What is Sengstaken-Blakemore tube
2. When to use SB tube
3. What do you need before you start
4. How to actually insert it
5. How to maintain traction
6. Aftercare and removal

What is Sengstaken-Blakemore tube

Sengstaken-Blakemore tube is a 3 lumen tube- one lumen to inflate gastric balloon, a second lumen to inflate oesophageal balloon and a third lumen to aspirate gastric contents. There is no oesophageal suction port. This causes saliva to pool in the oesophagus and thus put patients at risk of aspiration.
Commonly Minnesota tube is referred to as Sengstaken-Blakemore tube

Picture1:Minnesota tube or Modified Sengstaken-Blakemore tube

Minnesota tube- or modified Sengstaken-Blakemore tube is a four lumen tube with an additional lumen to aspirate oesophageal lumen to prevent aspiration from swallowed saliva and blood from the oesophageal varix

Linton-Nachlas tube: Single 600ml gastric balloon only

When to use SB tube

It is used in life threatening upper GI bleed from ruptured oesophageal/gastric varices when traditional treatment with band ligation or glue injection has failed or are not available

This is only temporary method to buy time for more definitive procedures to stop the bleeding.

What do you need before you start

1. The SB tube is normally kept in freezer- it helps insertion by improved stiffness
2. Keep ready two bladder wash syringes for suctioning the oesophageal and gastric lumen, another bladder wash syringe for inflating the gastric balloon
3. Stout metal artery forceps for clamping the balloon ports
4. If oesophageal balloon needs to be inflated in addition to the gastric balloon- You will need:

• A 50cc Luer Lock syringe
• An adaptor whose conical end will fit into the oesophageal port and the Luer lock end will fit into the sphygmomanometer ( the adaptor is available in the chest drain kit )
• A three way valve
• A sphygmomanometer with detachable arm cuff–  to remove the BP cuff and fit the Luer lock end of the chest drain adaptor to fit there

How to actually insert it

1. Debate regarding optimal place for the procedure: Resus vs. theatre: anaesthetist prefers theatre
2. Patient in normal endoscopy position
3. Airway protection- in general, patients who require balloon tamponade to control variceal bleeding should also be intubated. However airway protection is particularly important in
   • Encephalopathy
   • If Sao2<90%
   • Aspiration pneumonia


Picture2: Checking for leak

4. Check the balloons by inflating  air and checking for any leak
5. Smear plenty of KY gel and pass the tube through the mouth like an NG tube- It is kept in the freeze in theatres and Endoscopy unit-to increase the stiffness. Sometimes because of the curled position in which it is stored makes it very difficult to insert like NG tube and a laryngoscope and Magill’s forceps may be needed to guide it past crico-pharyngeus.


Picture3: The setting up of Modified Sengstaken-Blakemore tube

6. Once it has gone up to 45cm mark it’s tip is expected to lie in the gastric lumen- confirm by aspirating stomach content and checking pH – position to be checked later by portable CXR.
7. Once you are sure the tip is in the stomach, inflate the gastric balloon by inflating it with 200ml of air (and put two artery forceps as clamp and also insert the pegs supplied with the tube) and gently tugging it. Some  prefer to put contrast mixed water rather than air.
8. It should slide for some length and then halt as it abuts against the  GOJ –then push additional 50-100ml of air and pull the tube out to exert the pressure on the GOJ.
9. For majority of patients this is enough to stop the variceal haemorrhage. However, oesophageal balloon will need to be inflated, if the bleeding continues in spite of the gastric balloon inflation.
10. Clamp the tube in between air refills
11. Finally fix the tube and  keep a record of the distance of the tip from the incisor teeth- normally around 30-35cm mark
12. Initial success to control bleeding depends on
    • Operator experience
    • Concomitant therapy ( Terlipressin and antibiotics )

How to maintain traction

13. To maintain the pressure on GOJ- you will have to fix the tube with continued traction. We have noticed a variety of practices
    • To hang a bag of 500ml of saline by tying it to the loop of the clamp attached to the tube – the advantage of this technique is
      • Bag of saline is universal as opposed to a tennis ball- but units who use tennis ball normally store one ball with the tube
      • No pressure on the cheeks/lips unlike the tennis ball
      • The traction is measured ( 0.5 kg weight ) unlike unquantifiable traction strength which might vary from person to person
      • See the picture of how to do it below.



b. Pull  the tube and fix it on the side of the cheeks with elastoplasts under tension- not very reliable as    elastoplast may become loose and also the traction force will vary among individuals. However this is the most common practice.

c. Another method is to pull the tube and fix it on the side of the cheeks by passing it through a split tennis ball

14. If oesophageal balloon is inflated pressure should be accurately measured with a sphygmomanometer.
15. Inflate it to 25-40mm Hg. Normal portal pressure is <10 mm Hg; maximal pressure in portal hypertensive patients is never >30 mm Hg, therefore a pressure of 40 mm Hg is sufficient and remember the less the better.

Aftercare and removal:

1. Migration of gastric balloon in oesophagus can cause compression of trachea and respiratory distress. Keep a pair of scissors ready at the bedside in case of emergency – to cut the gastric balloon port to let the air escape
2. Instruction to suction both oesophageal and gastric lumen at intervals of 10 minutes increasing to 30 minutes and after stabilization hourly
3. Frequent oropharyngeal suction
4. Don’t forget antibiotic prophylaxis and continued terlipressin for at least 48hrs
5. Pressure in the oesophageal balloon to be relieved for 10minutes every 2hours to prevent pressure necrosis
6. Repeat endoscopy at 24 hours.
7. The Sengstaken tube should be removed in the endoscopy room
8. First deflate the oesophageal balloon, then take off the traction and finally remove the tube
9. Chance of rebleeding when balloon is deflated  is up to 50%
10. On second endoscopy it should be much easier to band or inject glue as bleeding hopefully would be under control, failing which patient should be referred for urgent TIPSS.
11. Serious complication can occur up to 15-20%
    • Oesophageal ulceration
    • Aspiration pneumonia

Here is the link for Sengstaken tube insertion  video:
No video found so far. One good link is http://emedicine.medscape.com/article/81020-media

Acknowledgement/Bibliography:

1. Helmy A et al. Review article: current endoscopic therapeutic options in the management of variceal bleeding. Aliment Pharmacol Ther. 2001 May;15(5):575-94.
2. Seet E et al. The Sengstaken-Blakemore tube: uses and abuses. Singapore Med J. 2008 Aug;49(8):195-7.
3. Han HY et al. Simple method for inflating and measuring oesophageal balloon pressure of Sengstaken-Blakemore tube. Intern Med J. 2006 Oct;36(10):684-5.
4. Kashiwagi H et al. Technque for positioning the Sengstaken-Blakemore tube as comfortably as possible. Surg Gynaecol Obstet 1991; 172

1. When to use Histoacryl glue
2. What is Histoacryl glue
3. How to prepare the glue
4. How to actually use it once it is ready
5. What are the complications

When to use Histoacryl glue

It is used to inject in the gastric varix to achieve haemostasis in case of acute bleeding.

Gastric varix occur in 20% patients of portal hypertension and risk of gastric variceal bleeding varies from 55% to 78% with a bleeding related mortality rate of 45%

It is tissue glue and can be issued to glue cut surface e.g. small incised wound in place of steristrip.

What is Histoacryl glue

Histoacryl® is an acrylic resin (N-butyl-2-cyanoacrylate) which rapidly polymerises in the presence of water joining the bonded surfaces together. It is available in 0.5ml ampoule.

Picture1: Histoacryl® glue

It is diluted in Lipiodol as it does not affect polymerization of cyanoacrylate and allow imaging should it embolize in the rare event.

Picture2:The diluent Lipiodol ultrafluid 100%v/v

How to prepare the glue

1. Wear protective eye goggles and gloves.
2. Draw 1ml  of Lipiodol  in a 2ml Luer lock syringe ( Lipiodol comes in 10ml ampoule)
3. Use of Luer lock syringe is preferable as it is quite hard to push the glue through the injection needle and there is a chance that the syringe can come loose from the injection needle spraying the glue everywhere.
4. Before you snap open the tip of the Histoacryl ampoule hold it vertically and tap the narrowed tip so that the solution settles in the bottom
5. Next draw  the whole ampoule (0.5ml of Histoacryl® ) of glue in the same syringe  and  gently shake
6. The glue has to be freshly made immediately before the injection into the varix.
7. Keep acetone handy as it is only dissolvable in acetone.

How to actually use it once it is ready

1. Use Large channel gastroscope (3.7 or 6mm working channel)
2. Prime the injection needle with 2ml of Lipiodol (some centre uses saline) to prevent injection of air into the varices and also to prevent glue settling in the gastroscope. Some centres use saline only.
3. It is preferable to use bigger bore injection needle (19G) as the glue mixture is very viscous and very hard to inject. Some centre uses injector needle with metal body/sheath rather than plastic body/sheath
4. Keep few 2ml syringes ready loaded with water for injection and 2-3 of 2ml syringes ready loaded with the glue mix.
5. Glue injection is usually done in retroflexed view. Once the needle is in the varix inject the glue mix. Remember once the syringe is empty, all the glue is still sitting in the injector needle (volume of the glue mix is 1.5ml and injector needle volume is 1.5-2ml)
6. Follow immediately with 2ml of water for injection flush to drive the glue mix from the lumen of the injection needle into the varix.
7. Withdraw the needle from the varix and flush another 2ml of water into the gastric lumen before withdrawing the needle back into the sheath- to prevent any glue mix from being left in the needle and occluding the needle or gastroscope.
8. Do not wait for the glue to solidify in the varix and then withdraw the needle for the fear of the hole made by you hosing- that might cause the needle to stick – forceful removal will result in de-roofing of the varix.
9. Withdraw the needle from the varix while assistant keeps flushing saline after the whole glue mix has been injected.
10. In event of the needle getting stuck in the varix- simply withdraw the needle into the sheath- keep the sheath attached to the varix. Cut the needle outside the scope and withdraw the scope. Subsequent management is not clearly defined – but watchful expectancy would not be a bad idea!
11. After the glue is injected prevent any temptation to suction. It is better to remove the suction button to avoid inadvertent suction of glue in the suction channel.
12. Limit each injection to 1ml to prevent embolism but can be repeated to completely obliterate all the tributaries.
13. Obliteration of the varix can be checked by probing with the injection needle when obliterated varix will feel firm whereas normal varix will feel spongy.
14. Because of fear of injection needle sticking to the scope, some centres practice withdrawing the scope with the needle in situ and the cut the tip of the needle outside before withdrawing the needle out of the scope.
15. Reported initial haemostasis rate of 87% to 100% with rebleeding  rate ranging from 24% to 50%.

What are the complications

1. Complication associated with Histoacryl® injection are embolism, sepsis, fistula and adherence of the needle to the glue within the varix
2. Damage to the scope if glue settles down in the biopsy channel fixing the injection needle to it

Here is the link for Intravariceal Cyanoacrylate (Histoacryl ) injection video

Video 1

Video 2

References/ Acknowledgement

1. Seewald S et al: A standardized injection technique and regimen ensures success and safety of N-butyl-2-cyanoacrylate injection for the treatment of gastric fundal varices (with videos): Volume68,No3:2008 Gastrointestinal Endoscop
2. Sohendra N et al: Endoscopic obliteration of large oesophagogastric varices with bucrylate.Endoscopy 1986: 18:25-6
3. Jalan R et al: UK guidelines on the management of variceal haemorrhage in cirrhotic patients. Gut; 46 (suppl III)
4. Poole hospital protocol for treatment of gastric varices using Histoacryl® glue

1. When to use banding device
2. Grades of varix and stigmata of recent haemorrhage
3. How to actually use it once it is set up
4. How to set it up

When to use banding device

Oesophageal variceal banding is done urgently for haemostasis from a ruptured oesophageal varix and electively as secondary prophylaxis to eradicate the varices.

Sclerotherapy of varices with ethanolamine has fallen in disrepute and should not be attempted.

There is no role for banding for isolated gastric varices

How to actually use it once it is set up

1. The patients need to be optimally resuscitated prior to endoscopy. An actively bleeding patient may also need airway protection with endotracheal intubation prior to endoscopy and banding.
2. Mapping the varices-Get your bearing right on your way in first time  as with the banding device on it will be difficult to see second time
   
   Picture1: Courtesy www.gastrointestionalatlas.com
3. Describe in your report- position and grade of the varix and whether any stigmata of recent haemorrhage were there or not and the Rockall score at the end of the procedure
4. Remember to put the bands on the varices as close to the GOJ as possible but above the Z line to ensure proximal decompression. Don’t put bands on the GOJ or in a hiatal hernia. Don’t put bands higher up as varices fill from below ( bottom 3-5cm)
5. Put plenty of jelly on the tip but avoiding the inside of the banding device.
6. Go just above the  GOJ and suck the varix into the banding device. To do that you will have to make the tip of the scope perpendicular to the wall of the oesophagus. Use big/small wheel to achieve this. You may have to use the wheel lock. Make sure the varix  completely obliterates the field (‘the red out’).
7. To ensure good suction- set the pump pressure to high and make sure the barrel of the banding device is snugly fitted to the tip of the scope avoiding any gap which will diminish the suction.
   
   Picture2:One oesophageal varix banded successfully
8. Fire/release  the band by turning the knob clock wise (you will hear and feel a click of band release) – still keep sucking for another  5 seconds and then let go.
9. Similarly put more bands on other variceal columns
10. Prescribe antibiotics and the terlipressin if not already on
11. If intubed for the procedure, the patient can be extubated if stable and the bleeding is controlled
12. BSG recommends that after the index banding  each varix should be banded with a single band at weekly intervals until variceal eradication.
13. Following eradication follow up endoscopy should be performed at 3 months and 6 months and then yearly.

Grades of varix and stigmata of recent haemorrhage

Grade of varix

1. Grade I: barely noticeable varix (remember after a big bleed varix can collapse to Grade I)
2. Grade II: present but flattens on insufflations
3. Grade III: Varix up to 30% of the lumen ( most varices)
4. Grade IV: Varix up to 60% of the lumen
5. Grade V: Complete obliteration of the lumen by the varix

Stigmata of recent haemorrhage (SRH) :  Red spot/ Red Wale markings- Erythematous raised area on the varix indicating high risk of bleeding

How to set it up

We will describe two commonly used banding devices- Boston’s 7 shooters and Wilson-Cook’s 4/6/10 shooters.

Seven shooters – SpeedBand SuperView Super 7™ ( Boston Scientific)

1. Inside the pack you will find the ligator handle with the metal string attached to it, the barrel with the bands and the irrigation catheter.
   
   Picture3: The ligator handle with the metal string
2. Send the  wire of the handle through the biopsy  channel
   
   Picture4: The ligator handle from another side showing the fastening Velcro and white side port for irrigation
3. Insert the ligator handle into the biopsy channel by pushing the metallic end and fix by tightening the Velcro fasteners
   
   Picture5: The barrel with the bands with the attached thread
4. When the metal string of the ligator handle  comes out of the tip of the endoscope loop the string of the ligating device/barrel through it and then pull it from the top of the biopsy channel by turning the knob on the handle clockwise (it can only turn in one direction)
5. Stop turning when the barrel is close to the tip of the endoscope. Push the ligating barrel snugly (if not snugly fitted the barrel might come loose in the oesophagus once all the bands are fired) into the tip of the endoscope and keep the string taut by pulling the string from top and fixing it by passing it through the extended axle of the spool (white arrow in the picture)
6. When pushing the barrel into the tip of the scope- align the black mark of the barrel along the biopsy channel and remove the plastic covering (it has got a red ring on plastic) the barrel after that.
   
   Picture 6: Showing the attachment of the irrigation catheter
7. If needed irrigation catheter can be fitted to the white irrigation port on the handle
   
   Picture 7: Courtesy Boston Scientific
8. The ‘last but one band’ ( the sixth band in the seven shooters ) is white/yellow colour – rest are blue
9. The super 7 is now ready to be used

Six shooters- Wilson-Cook banding device (Saeed multiband ligator- 4/6/10 shooter)

1. Inside the pack you will find ligator handle, loading catheter, trigger cord with Opti-Vu barrel (with the bands on) and irrigation adaptor
   
   Picture 8: Diagram Courtesy Wilson-Cook Medical GI Endoscopy
2. First insert the ligator handle into the endoscope accessory channel- through the rubber biopsy channel cap. Make sure the handle is on two-way position and not firing position.
3. Introduce either end of the loading catheter through the white seal in the ligator- align the s-end of the loading catheter with the slit in the white seal of the introduction port. If you don’t align it is very difficult to push through.
4. Advance the catheter till it exits the tip of the endosocpe
5. Attach the trigger cord to the hook on the end of the loading catheter, leaving approximately 2 cm of trigger cord between the knot and the hook
6. Withdraw the loading catheter from above making the trigger cord to come out through white seal.
7. Then push the barrel containing the bands to the tip of the endoscope tip- avoid holding the actual bands. If you don’t push well- during sucking the varix into the barrel, suction won’t be optimum.
8. Also remember this barrel does not fit a therapeutic (salmon/red color coded scope) scope tip.
9. Next place the trigger cord in the slot on the spool of the ligator handle and pull down until the knot is seated in the hole of the slot. The knot must be seated into the hole for the handle to function properly.
10. With the handle in the two-way position, rotate the handle clockwise to wind the trigger cord onto the handle spool (do carefully as too much force might deploy a band)
11. With handle in the in the two way position, introduce the endoscope again
12. Then place the handle into firing position by pushing it inwards- it is marked on the handle ( see picture)
13. The 6 shooters is now ready to be used.
14. Irrigation can be done by inserting the irrigation adaptor into the white seal on the handle.

Here is the link for EVL  Video:

Acknowledgement/Bibliography:

1. Sarin SK et al. Prospective randomized trial of endoscopic sclerotherapy versus variceal band ligation for esophageal varices: influence on gastropathy, gastric varices and variceal recurrence. Journal of Hepatology 1997;26:4: 826-832
2. Stiegman GV et al. Endoscopic elastic band ligation for active variceal haemorrhage. Am Surg 1989;55(2):124-128
3. Sharara AI et al. Gastroesophageal variceal hemorrhage. N Engl J Med 2001; 345(9): 669-681
4. Product guide of the respective companies- Boston Scientific and Wilson-Cook