Tension pneumothorax following balloon tamponade and esophagogastroduodenoscopy for variceal hemorrhage: case report and brief review of the literature
CCCF ePoster library. Balan M. Nov 2, 2016; 150985
Dr. Marko Balan
Dr. Marko Balan
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Topic: Clinical Case Report

Tension pneumothorax following balloon tamponade and esophagogastroduodenoscopy for variceal hemorrhage: case report and brief review of the literature


Balan, Marko1; Babar Haroon2
1
Department of Medicine, Dalhousie University, Halifax, Canada; 2Department of Critical Care Medicine, Division of General Internal Medicine, Dalhousie University and the Queen Elizabeth II Health Sciences Centre, Halifax, Canada



Abstract:

INTRODUCTION: A 50 year-old male with a history of alcohol-related cirrhosis presented to the Emergency Department (ED) of a tertiary care hospital with acute abdominal pain and several episodes of frank hematemesis. On presentation to the ED, the patient was agitated but initial vital signs were within normal limits. He was urgently intubated due to agitation and for airway protection, and was administered intravenous normal saline, packed red blood cells, octreotide and pantoprazole. A Sengstaken-Blakemore tube was then inserted with placement confirmed by auscultation. The gastric balloon was inflated with 250mL of air and one kilogram of vertical traction was applied to the system. The patient was then transferred to the Intensive Care Unit where a chest radiograph revealed the inflated gastric balloon in left hemithorax, suspicious for esophageal placement (see Figure 1). The balloon was deflated, removed and urgent upper endoscopy was conducted, which revealed an extensive laceration of the mid and upper third of the esophagus and a large bleeding varix. The varix was band ligated. During endoscopy the patient developed hypoxia, increased ventilatory pressures and severe hemodynamic instability (nadir SBP 50mm Hg). Physical examination revealed absence of breath sounds on the left chest. Urgent chest radiography revealed a left-sided tension pneumothorax (see Figure 2). Tube thoracostomy was performed resulting in improvement of the patient’s respiratory and hemodynamic variables. He was then taken to the operating room for a left thoracotomy and repair of esophageal perforation. Ten days after presentation he died of hepatic failure. DISCUSSION: Variceal hemorrhage is a common complication in patients with cirrhosis and is associated with mortality rates of 10-20% 1, 2. If maximal medical management fails to control upper gastrointestinal hemorrhage, balloon tamponade may be indicated for temporary stabilization in select patients. This case illustrates a serious complication of this intervention - esophageal rupture following balloon tamponade insertion. Subsequent development of tension pneumothorax during upper endoscopy was likely due to passage of air from the esophageal lumen to the pleural space during endoscopic insufflation. Autopsy studies have described evidence of communication between esophageal perforations and pleural/mediastinal spaces 3, 4, but to our knowledge the development of tension pneumothorax as a consequence has not been reported. In addition to esophageal rupture, other serious complications with the use of Sengstaken-Blakemore tubes have also been reported, including airway compression, pulmonary aspiration, and cardiac arrest. Historical reports describe serious complications of balloon tamponade use occurring in 15-35% 5, 6 of patients with 8-22% of all patients suffering death 7. Minor complications are very common and include chest discomfort, gastric erosion, and nasal/oral mucosal tears. Due to the significant risks associated with this intervention, some authors have advocated for radiographic or ultrasonographic verification of balloon position prior to inflation 8, 9. CONCLUSION: Despite advancements in medical and endoscopic interventions for variceal bleeding, esophageal tamponade may be indicated for temporary stabilization of patients. Critical care clinicians should be aware of indications, complications and correct insertion techniques of gastro-esophageal balloon tamponade devices.


References:

1. D’Amico G, De Franchis R, & Cooperative Study Group. Upper digestive bleeding in cirrhosis. Post therapeutic outcome and prognostic indicators. Hepatology. 2003;38:599-612.
2. de Franchis R, on behalf of the Baveno VI Faculty. Expanding consensus in portal hypertension Report of the Baveno VI Consensus Workshop: Stratifying risk and individualizing care for portal hypertension. J Hepatol. 2015; 63:743-752.
3. Lin CT, et al. Sengstaken-Blakemore tube related esophageal rupture. Rev Esp Enferm Dig. 2010; 102(6):395-396.
4. Nielsen TK, Charles AV. Lethal esophageal rupture following treatment with Sengstaken-Blakemore Tube in management of variceal bleeding: a 10-year autopsy study. For Sci Int. 2012;222:e19-e22.
5. Haddock G, et al. Esophageal tamponade in the management of acute variceal hemorrhage. Dig Dis Sci. 1989; 34(6):913-918.
6. Panés J, et al. Efficacy of balloon tamponade in treatment of bleeding gastic varices and esophageal varices results in 151 consecutive episodes. Dig Dis Sci. 1988; 33(4): 454-459.
7. Chojkier M, Conn HO. Esophageal tamponade in the treatment of bleeding varices a decadal progress report. Dig Dis Sci. 1980; 25(4): 267-272.
8. Chong CF. Esophageal rupture due to Sengstaken-Blakemore tube misplacement. World J Gastroenterol. 2005; 11(41):6563-6565.
9. Lock G, et al. Inflation and positioning of the gastric balloon of a Senstaken-Blakemore tube under ultrasonographic control. Gastrointest Endosc. 1997; 45:538.



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