State University of New York Upstate Medical University Syracuse, NY
Pujitha Kudaravalli, MBBS1, Sheikh A. Saleem, MD2, Venkata Satish Pendela, MD3, Savio John, MD2; 1State University of New York Upstate Medical University, Syracuse, NY; 2SUNY Upstate Medical University, Syracuse, NY; 3Rochester General Hospital, Rochester, NY
Introduction: The incidence of Downhill esophageal varices is 0.4-10% and bleeding from these varices account for only 0.1% of acute esophageal bleeding. Our case report highlights the diagnostic and therapeutic challenges associated with this rare condition.
Methods: A 78-year-old female with a past medical history of Class II pulmonary hypertension on tadalafil and atrial fibrillation presented to the hospital with melena. On examination, heart rate was 59 beats/minute and blood pressure was 112/42 mm Hg. Hb/Hct (g/dL/%) was 8.6/25.5. Esophagogastroduodenoscopy (EGD) showed grade I proximal esophageal varices with old blood in the pharynx (shown in figure 1). No signs of nasopharyngeal bleed were found on ENT exam. The patient was discharged on pantoprazole. She was re-admitted two more times within a month with gastrointestinal bleeding. A repeat nasopharyngolaryngoscopy showed coagulated blood at the post cricoid region of the glottis without active signs of bleeding. She had an EGD during every admission with no identifiable source of active bleeding. Work-up for cirrhosis was negative. CT thorax was negative for superior vena cava obstruction. During this period the patient had increasing oxygen requirements from fluid overload. Echocardiography showed PA systolic pressure of 87 mm Hg, impaired right ventricular function and severe tricuspid regurgitation. The family sought comfort measures in view of worsening clinical status and endoscopic therapy of the downhill varices was hence not attempted. Discussion: Intrinsic narrowing of super vena cava (SVC) from malignancy or catheter related thrombosis (most common), extrinsic compression of SVC from intrathoracic goiter, thymoma and lung cancer are some causes of downhill varices. The increased pressure in the SVC secondary to pulmonary hypertension can rarely cause downhill varices. The extent of esophageal varices is related to the level of SVC-azygous vein junction obstruction. High degree of suspicion is needed, as in our patient, when there no active bleeding on EGD or SVC obstruction is seen on imaging. Early diagnosis is crucial as the cornerstone of management is treatment of SVC obstruction. Balloon angioplasty, SVC stenting, vascular bypass are a few treatment options to relieve SVC obstruction. When the underlying medical disorder cannot be corrected, downhill varices can be controlled using endoscopic band ligation, sclerotherapy, or balloon tamponade although the risk of perforation in this region of esophagus is very high.
Esophagogastroduodenoscopy showing grade I proximal esophageal varices
Disclosures: Pujitha Kudaravalli indicated no relevant financial relationships. Sheikh Saleem indicated no relevant financial relationships. Venkata Satish Pendela indicated no relevant financial relationships. Savio John indicated no relevant financial relationships.