Abstract Introduction Esophageal variceal (EV) hemorrhage is a life-threatening emergency and a major cause of mortality among patients with cirrhosis. While classically linked to alcohol-related liver disease, other etiologies such as autoimmune hepatitis or primary biliary cholangitis (PBC) can also lead to portal hypertension and variceal rupture. Balloon tamponade using a Sengstaken-Blakemore tube is typically a last-resort, temporizing measure for uncontrolled bleeding. However, its use in non-alcoholic cirrhosis—and particularly with incomplete balloon functionality—is rarely documented. Case Description An 84-year-old woman with autoimmune hepatitis-PBC overlap syndrome and decompensated cirrhosis presented with large-volume hematemesis one week after undergoing endoscopic variceal ligation (five bands). At home, she experienced recurrent hematemesis and suffered pulseless electrical activity cardiac arrest during ambulance transport. Return of spontaneous circulation was achieved in the emergency department (ED) after activation of a massive transfusion protocol (MTP).She was intubated, transferred to the medical intensive care unit, and received two additional MTP units for ongoing hemorrhagic shock. A Sengstaken-Blakemore tube was inserted, but the gastric balloon failed to inflate—likely due to a manufacturing defect or valve malfunction. Given ongoing exsanguination, the esophageal balloon alone was inflated under continuous hemodynamic and airway monitoring. Rapid clinical tamponade was achieved, with immediate cessation of hematemesis, stabilization of vital signs, and discontinuation of vasopressors. She was subsequently transferred to the operating room for definitive management with transjugular intrahepatic portosystemic shunt (TIPS). Unfortunately, she suffered cardiac arrest during the procedure, and resuscitative efforts were not pursued per family wishes. Discussion This case highlights the critical role of adaptive management in refractory EV hemorrhage. Despite incomplete device function, isolated esophageal balloon inflation successfully controlled bleeding and reversed hemorrhagic shock. Although balloon tamponade is classically a bridge to TIPS or definitive endoscopic therapy, this case demonstrates that hemostasis can still be achieved when only partial device deployment is possible. The pathophysiologic benefit likely stems from direct compression of distal varices within the lower esophagus, which can transiently reduce portal pressure and variceal outflow. Learning Point In life-threatening variceal bleeding, isolated esophageal balloon inflation may provide effective temporizing hemostasis when gastric balloon inflation fails. Prompt, flexible decision-making and close monitoring can be lifesaving in patients with non-alcoholic cirrhosis presenting with refractory EV hemorrhage. This abstract is funded by: None
Srivastava et al. (2026) studied this question.