430 Balloon Tamponade Utilization for Severe Esophagitis Causing Hemorrhagic Shock

Abstract

Esophagitis as a cause of upper gastrointestinal bleeding (UGIB) is a difficult entity to treat and is associated with significant morbidity. Epidemiologic studies note a 7-18% incidence of significant hemorrhage due to esophagitis. Current existing treatment options for UGIB complicated by hemorrhagic shock secondary to severe esophagitis are limited when there is a lack of response to proton pump inhibitor (PPI) medical therapy. Methods We present a case series of two patients who developed hemorrhagic shock from esophagitis, underwent endoscopic evaluation revealing limited treatment options, and ultimately required balloon tamponade resulting in successful resolution of bleeding and improvement in hemodynamics. A 55-year-old male with history of alcoholism complicated chronic pancreatitis and esophagitis presented with seizures. On admission he experienced hemorrhagic nasogastric tube output, anemia unresponsive to transfusions and hemodynamic instability. A 44-year-old patient with decompensated alcoholic cirrhosis was initially admitted for renal failure, and during the hospitalization developed melena and hemorrhagic shock requiring transfusions and vasopressors. The patients were promptly started on PPI infusion. Results Both patients underwent esophagogastroduodenoscopy revealing severe bleeding esophagitis extending from the gastroesophageal junction to the proximal esophagus and no varices. Active bleeding was not amenable to endoscopic therapy and both patients underwent balloon tamponade placement. The first patient required inflation of both the esophageal and gastric balloons for control of hemorrhage for 6 hours whereas the second patient required just gastric balloon inflation for 12 hours. Bleeding, transfusion requirement, and hemodynamics improved in both patients. Second look endoscopy demonstrated resolution of bleeding and hemostatic spray was applied to the esophagus prophylactically. Neither patient had recurrence of bleeding during the hospitalization. Conclusion UGIB secondary to esophagitis is difficult to control due to the highly vascularized nature of the esophagus. Endoscopic therapies are limited in extensive mucosal injury and risks of complications such as perforation are high. Other therapeutic options such as angiography are restricted due to vascular collateralization and surgical interventions have high morbidity and mortality. Balloon tamponade provides a viable treatment option for severe UGIB secondary to esophagitis that is not responsive to medical therapy.