Letter: Unusual complication of use of Sengstaken-Blakemore tube.

The patient was a 55-year-old male alcoholic who presented with bleeding oesophageal varices. During the course of management a SengstakenBlakemore tube was passed and inflated with a Gastrografin and saline solution.1 2 The position of the tube was checked radiologically. Despite sedation the patient was restless and succeeded in pulling the tube so that the oesophageal balloon was partly out of his mouth. The oesophageal balloon was immediately deflated, but no Gastrografin could be aspirated from the gastric balloon. The tube was passed back to the stomach and restored to the traction position. An x-ray (fig. 1) showed the gastric balloon still inflated and in position, but the distance between it and the now malpositioned oesophageal balloon showed that the patient's sudden traction had pulled the gastric balloon a considerable distance down the tube. Gastrografin injected via the gastric balloon's filling lumen did not increase the balloon's size, nor could it be reaspirated, showing that the balloon had been disconnected from its filling lumen.