In cases of refractory bleeding, balloon tamponade with Sengstaken-Blakemore tube may be necessary, usually as a bridge to further endoscopy or treatment of the underlying cause of bleeding (usually portal hypertension). Methods of treating the portal hypertension include: transjugular intrahepatic portosystemic shunt (TIPS), or a distal splenorenal shunt procedure or a liver transplantation.
Algorithm of the current management of acute bleeding from ruptured esophageal varices. *Self-expandable esophageal metallic stent may represent an alternative to balloon tamponade in this situation. **Preferably TIPS with PTFE-covered stents (from reference , with permission).