Inserting the Sengstaken-Blakemore tube successfully in a difficult case of uncontrollable esophageal variceal bleeding, using sutures and an endoscope.

Uncontrolled acute esophageal variceal bleeding carries a high mortality rate. When endoscopic therapy fails, a temporising measure such as inserting a Sengstaken-Blakemore (SB) tube secures hemostasis. This allows for patient stabilisation, correction of coagulopathy and arrangement of definitive therapies such as transjugular intrahepatic portal systemic shunting or repeat endoscopy. However, inserting an SB tube blindly carries the potential risk of tube malposition. This may arise due to either the operator’s inexperience or a difficult pharyngo-esophageal anatomy. In these cases, inflating the gastric balloon in the esophagus can result in esophageal rupture, mediastinitis and death. Another immediate complication related to the insertion of a SB tube includes inadvertent endotracheal intubation. This may result in tracheal/bronchial perforation or obstruction. At times, insertion of the SB tube can be unsuccessful due to coiling in the posterior pharynx. Failure of insertion of the SB tube and incorrect positioning also results in continued gastrointestinal bleeding. We describe a case of a difficult SB tube intubation in a patient with uncontrolled esophageal variceal bleeding. The tube was unsuccessfully inserted despite multiple attempts. Using sutures and an endoscope, we successfully inserted the SB tube at the bedside.