Warren Alpert Medical School of Brown University Providence, RI
Daniel Marino, MD, MBA1, Debashis Reja, MD2, Maggie Cheung, MD3, Kristina Katz, MD4; 1Warren Alpert Medical School of Brown University, Providence, RI; 2Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ; 3Robert Wood Johnson Medical School, Rutgers University, New Brunswick, NJ; 4University Medical Center of Princeton at Plainsboro, Princeton, NJ
Introduction: “Downhill” esophageal varices are found in the upper two thirds of the esophagus and are a result of vascular obstruction of the superior vena cava (SVC).1 They account for 0.4% of all esophageal varices and are a rare cause of gastrointestinal bleeding.2 We present a case of GI hemorrhage found to have downhill esophageal varices on endoscopy. The case serves to remind that while rare, this etiology remains in the differential of a GI bleed, especially in patients with signs of SVC syndrome.
Methods: A 69-year-old woman with a history of CAD with nine stents, COPD, ESRD on HD presented to the ED after outpatient hemoglobin of 6.9. The patient reported epigastric pain associated with melena, but no hematemesis or hematochezia. On exam, the patient had mild swelling of her face and bilateral upper extremities. An EGD was performed on day of admission and revealed prominent blood vessels in the upper (Figure 1) and middle third of the esophagus consistent with “downhill” varices. No endoscopic treatment was performed as there was no stigmata of recent bleeding. A contrast-enhanced CT chest revealed a chronic SVC thrombus in the left internal jugular vein associated with a tunneled dialysis catheter (Figure 2). Vascular surgery performed a cavagram (Figure 3), angioplasty, and SVC stent placement. The patient’s hemoglobin remained stable and she was discharged with outpatient follow-up and plan for repeat EGD. Discussion: Unlike “uphill” esophageal varices, which are located at the lower esophagus due to portal hypertension, “downhill” esophageal varices are found in the upper two thirds of the esophagus and result from SVC obstruction.1 SVC obstruction can be due to malignancy such as lymphomas or non-malignant causes, such as mediastinal fibrosis or as in our patient, a dialysis catheter.3 Because of the location and pathophysiology of downhill esophageal varices, management differs from that of uphill varices. Proton pump inhibitors likely provide minimal benefit as the proximal esophageal varices are not exposed to gastric acid. Octreotide is also unlikely beneficial as downhill varices are not caused by increased portal pressures. The most definitive treatment is to decompress and revascularize the SVC.4 Given that downhill esophageal varices are rare, comprising less than 1% of all esophageal varices, it is important to keep it on the differential of GI bleeding especially in patients with signs and symptoms of SVC syndrome.
Endoscopic appearance of downhill varices in upper third of the Esophagus
Contrast enhanced CT with SVC Thrombus
Pre-intervention cavagram of SVC demonstrating occlusion
Disclosures: Daniel Marino indicated no relevant financial relationships. Debashis Reja indicated no relevant financial relationships. Maggie Cheung indicated no relevant financial relationships. Kristina Katz indicated no relevant financial relationships.