Esophageal Varices and Blakemore Tube
Patient presentation:
K.P., 54 year old male with PMH ETOH abuse - last drink 2 years ago, Hep C, Cirrhosis, upper GI bleed, varices s/p failed TIPS procedure (TIPS= Transjugular Intrahepatic Portosystemic Shunt, a procedure done in IR to treat portal hypertension which shunts the blood flow from the portal vein through to the heptatic vein) and pancreatitis admitted to hospital for altered mental status. K.P. was found to have hepatic encephalopathy with an serum ammonia level of 60 and was being treated on the floor with lactulose. However, while on the floor, K.P. complains of nausea and vomits large amounts of bright red blood. K.P. appears pale but remains jaundiced and BP drops to 60’s / 30’s HR 120’s sinus tachycardia, RR 12 and O2sat 94% on RA. Stat CBC, type and screen, and coags sent and pt given 2 liters NS and sent to the MICU for further management.
Labs:
Na+ 133, K+ 3.5, BUN 19, Creatinine 0.8
WBC 7.2, Hbg 4, Hct 10, Plts 20, INR 3.4
Albumin 2.0, Alkphos 300, AST 230, ALT 120, Total Bilirubin 4.5
Differential Diagnosis:
Given history and presentation, upper GI bleed is most likely due to varices, but gastric ulcers cannot be ruled out without endoscopy.
Treatment:
Once K.P. arrives at MICU, he continues to have bloody emesis with clots. K.P. intubated for airway protection. Cordis is placed and rapid infuser in used to give multiple units of PRBCs, FFP, and PLTS. PIV also placed to start Levophed® drip for hypotension and Protonix® and octreotide drips. K.P. also given DDAVP intravenously. Post intubation, K.P. was placed on fentanyl and propofol drips for sedation. Upper endoscopy is performed at the bedside by GI Attending and Fellow. Variceal bleeding noted and there is failure to stop the hemorrhage via cauderization and banding. Decision made to place Blakemore tube (device used to temporarily tamponade any acute variceal bleed). Blakemore is inserted by the GI Fellow and Attending, CXR confirms placement and balloons inflated and connected to traction. CBC and coags monitored q2 hours initially. K.P. also placed on broad spectrum antibiotics for suspected aspiration and electrolytes are replaced as needed.
Outcome:
In the end, the prognosis was poor and patient bleeding could not be controlled even after going to IR for angio. K.P. eventually passed away of complications with bleeding and extended use of the Blakemore eroding the esophagus.