INTRODUCTION: In patients with massive variceal bleeding, placement of a Minnesota tube or similar device is sometimes necessary to tamponade culprit varices at the gastroesophageal junction. Traditionally the gastric balloon is inflated in two stages: first 50mL of air is insufflated after the tube has been advanced to the 50cm mark; after radiographic confirmation of gastric balloon position, 300mL of air is added and traction is applied. Simple auscultation for air infused through the gastric port has been associated with serious complications arising from unrecognized balloon malposition, and is therefore not recommended as a substitute for radiographic confirmation. We describe two cases of variceal bleeding where Minnesota tube placement was confirmed using bedside ultrasonography by the treating intensivists, allowing balloon inflation and traction to be applied safely before portable radiography was available.
CASE PRESENTATION: Case 1. A 52-year-old woman with a history of orthotopic liver transplantation was transferred to our facility for management of suspected graft rejection. On her ninth hospital day, she had an episode of hypotension and a gastric lavage demonstrated bright red blood. Her heart rate was 130 beats per minute and blood pressure was 100/55 mmHg. In the next hour, after receiving two units of packed red blood cells, 2 units of fresh frozen plasma and 1 six-pack of pooled platelets, the patient’s hemoglobin dropped from 9g/dL to 5.2g/dL. A Minnesota tube was inserted. A 5-2 MHz 65-mm broadband curvilinear transducer was placed transversely over the patient’s left upper quadrant after insertion of the Minnesota tube. Echogenic contrast was easily visualized after infusion of 10mL of agitated saline through the gastric port of the device. Examination of the patient’s left upper quadrant with a 12-4 MHz 42-mm broadband linear transducer revealed an acoustic shadow within the stomach, corresponding to the device tubing. Case 2. A 63-year-old morbidly obese man with a history of alcoholic cirrhosis was transferred from an outside hospital for management of presumed variceal bleeding. In the 4 hours prior to arrival he had received six units of packed red blood cells, six units of fresh frozen plasma and two six-packs of pooled platelets. His heart rate was 135 beats per minute and blood pressure was 95/50 mmHg. The initial hemoglobin was 11.9 g/dL, and lactate was 11.3 mMol/L. A Minnesota tube was inserted. A 5-2 MHz 65-mm broadband curvilinear transducer was placed transversely over the patient’s left upper quadrant. Echogenic contrast was visualized after infusion of 10mL of agitated saline through the gastric port of the device. In addition, the gastric balloon was visualized prior to agitated saline infusion, though with some difficulty. In contrast to the first case, the Minnesota tubing was not visualized with the 12-4 MHz 42-mm broadband linear transducer.
DISCUSSIONS: To the best of our knowledge, these two cases are the first published descriptions of Minnesota tube placement confirmation with ultrasound by the treating clinician. In both cases, the exam was performed contemporaneously with resuscitations of hemodynamically unstable patients. For the purpose of verifying a gastric position of the tamponade balloon, ultrasound served as a substitute for portable radiology - and therefore facilitated earlier control of hemorrhage. It may not always be possible to confirm placement using ultrasound on account of body habitus or overlying bowel loops, and in those cases radiographs should still be obtained.
CONCLUSION: Minnesota tube placement can be confirmed using bedside ultrasound by the treating clinician, obviating the need to wait for portable radiology prior to tamponade balloon inflation. In hemodynamically unstable patients this may be clinically significant by facilitating more rapid control of variceal hemorrhage.
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