Case Report
Copyright ©The Author(s) 2021. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Clin Cases. Jan 16, 2021; 9(2): 372-378
Published online Jan 16, 2021. doi: 10.12998/wjcc.v9.i2.372
Lateral position intubation followed by endoscopic ultrasound-guided angiotherapy in acute esophageal variceal rupture: A case report
Ting-Ting Wen, Zheng-Lv Liu, Min Zeng, Yu Zhang, Bao-Li Cheng, Xiang-Ming Fang
Ting-Ting Wen, Zheng-Lv Liu, Yu Zhang, Bao-Li Cheng, Xiang-Ming Fang, Department of Anesthesiology, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou 310003, Zhejiang Province, China
Min Zeng, Department of Anesthesiology, The Second Hospital of Yinzhou, Ningbo 315100, Zhejiang Province, China
Author contributions: Wen TT, Zhang Y and Cheng BL were the patient’s anesthesiologists, reviewed the literature and drafted the manuscript; Liu ZL and Zeng M reviewed the literature and drafted the manuscript; Fang XM proofread the manuscript; All authors issued final approval of the version for submission.
Supported by National Natural Science Foundation of China to CBL, No. 81971876; and National Key Research and Development Program of China to FXM, No. 2018YFC2001900.
Informed consent statement: Informed written consent was obtained from the patient for publication of this report and any accompanying images.
Conflict-of-interest statement: The authors declare that they have no conflict of interest.
CARE Checklist (2016) statement: The authors have read the Care Checklist (2016) and prepared the manuscript accordingly.
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See:
Corresponding author: Xiang-Ming Fang, MD, Chief Doctor, Dean, Director, Full Professor, Department of Anesthesiology, The First Affiliated Hospital, School of Medicine, Zhejiang University, No. 79 Qingchun Road, Hangzhou 310003, Zhejiang Province, China.
Received: June 6, 2020
Peer-review started: June 6, 2020
First decision: August 8, 2020
Revised: August 22, 2020
Accepted: November 29, 2020
Article in press: November 29, 2020
Published online: January 16, 2021

Massive esophageal variceal bleeding can be catastrophic, leading to high morbidity and mortality. Patients experiencing massive esophageal variceal bleeding are at high risk of aspiration and hemorrhagic shock in acute episodes. Intubation and bleeding control are the two essential steps for resuscitation of these patients.


A 47-year-old male patient was admitted to our hospital with upper digestive tract bleeding. He was diagnosed with alcohol-induced liver cirrhosis and consequent esophagogastric varices. As he did not show a good response to somatostatin and Sengstaken-Blakemore tube placement, the patient was scheduled for endoscopic angiotherapy under anesthesia. Preoperative assessment showed an ASA physical status of III and Child-Pugh classification B. However, massive hemorrhage occurred just after induction of anesthesia.  Intubation by video-guided laryngoscopy in the lateral decubitus position was attempted twice and was successful. After that, an experienced endoscopic ultrasound (EUS) specialist performed angiotherapy and occluded the culprit vessel. An ultra-thin gastroscope was then inserted into the endotracheal tube to extract the blood observed in the lobar bronchi. The patient suffered hemorrhagic shock with an estimated blood loss of 1500 mL in 20 min and remained in the intensive care unit for two days. The patient was discharged from our hospital eight days later without major complications.


Intubation in the lateral decubitus position and EUS-guided treatment can be life-saving procedures in patients with massive upper gastrointestinal hemorrhage.

Keywords: Intubation in the lateral position, Endoscopic ultrasound, Esophageal varices, Angiotherapy, Ultra-thin gastroendoscope, Case report

Core Tip: Intubation in the lateral decubitus position, which can be easily achieved with the help of video-guided laryngoscopy, is an option in emergency situations to protect the airway. In addition, endoscopic ultrasound (EUS) is effective in stopping acute massive hemorrhage from esophageal varices due to the enhanced sonography of EUS from fluid.  This case highlights the importance of both the intubation and EUS-guided therapy in the management of acute massive hemorrhage caused by esophageal varices.