Standard gastroscope-guided endotracheal intubation in the lateral position for life-threatening variceal bleeding: a report of technical feasibility and airway safety.

backgroundPatients with acute upper gastrointestinal hemorrhage (UGIH) often present with airway contamination due to hematemesis and gastric reflux. Conventional endotracheal intubation (ETI) in the supine position faces challenges such as limited visualization and high aspiration risk. While securing the airway and controlling bleeding are both critical during resuscitation, simultaneous achievement of these goals remains technically difficult. CASE PRESENTATION: A 56-year-old woman with esophageal variceal rupture presented with hemorrhagic shock. After left-lateral positioning and rapid-sequence induction, a cuffed endotracheal tube pre-loaded with a J-tipped guidewire was advanced through the right channel of a bite block into the oropharynx. Under continuous direct visualization provided by a standard diagnostic gastroscope, the tube was steered into the glottis on the first attempt. The scope was then advanced through the tube into the esophagus, permitting immediate endoscopic band ligation of all bleeding varices. The entire process from securing the airway to endoscopic access was completed without apparent delay, with no clinically evident aspiration and with maintained hemodynamic stability.

conclusionsThis case demonstrates the technical feasibility of standard gastroscope‑guided intubation in the lateral decubitus position for airway management in massive upper gastrointestinal (GI) bleeding with hypovolemic shock. The procedure enabled rapid airway control without repositioning‑induced hemodynamic instability, allowed seamless transition to endoscopic hemostasis, and was not associated with visible aspiration or mucosal injury. Considering the limitations of a single case, the approach may reduce risk and appears feasible in this instance. These findings are descriptive and not generalizable. The technique may be considered a potential alternative in selected high‑risk "bloody airway" scenarios when advanced bronchoscopic equipment is unavailable. Further validation in larger studies is needed.