Bleeding 'downhill' esophageal varices associated with benign superior vena cava obstruction: Case report and literature review

Michael Loudin, Sharon Anderson, Barry Schlansky

Research output: Contribution to journalArticle

1 Citation (Scopus)

Abstract

Background: Proximal or 'downhill' esophageal varices are a rare cause of upper gastrointestinal hemorrhage. Unlike the much more common distal esophageal varices, which are most commonly a result of portal hypertension, downhill esophageal varices result from vascular obstruction of the superior vena cava (SVC). While SVC obstruction is most commonly secondary to malignant causes, our review of the literature suggests that benign causes of SVC obstruction are the most common cause actual bleeding from downhill varices. Given the alternative pathophysiology of downhill varices, they require a unique approach to management. Variceal band ligation may be used to temporize acute variceal bleeding, and should be applied on the proximal end of the varix. Relief of the underlying SVC obstruction is the cornerstone of definitive treatment of downhill varices. Case presentation: A young woman with a benign superior vena cava stenosis due to a tunneled internal jugular vein dialysis catheter presented with hematemesis and melena. Urgent upper endoscopy revealed multiple 'downhill' esophageal varices with stigmata of recent hemorrhage. As there was no active bleeding, no endoscopic intervention was performed. CT angiography demonstrated stenosis of the SVC surrounding the distal tip of her indwelling hemodialysis catheter. The patient underwent balloon angioplasty of the stenotic SVC segment with resolution of her bleeding and clinical stabilization. Conclusion: Downhill esophageal varices are a distinct entity from the more common distal esophageal varices. Endoscopic therapies have a role in temporizing active variceal bleeding, but relief of the underlying SVC obstruction is the cornerstone of treatment and should be pursued as rapidly as possible. It is unknown why benign, as opposed to malignant, causes of SVC obstruction result in bleeding from downhill varices at such a high rate, despite being a less common etiology of SVC obstruction.

Original languageEnglish (US)
Article number134
JournalBMC Gastroenterology
Volume16
Issue number1
DOIs
StatePublished - Oct 24 2016

Fingerprint

Superior Vena Cava Syndrome
Esophageal and Gastric Varices
Varicose Veins
Hemorrhage
Superior Vena Cava
Pathologic Constriction
Melena
Hematemesis
Christianity
Indwelling Catheters
Gastrointestinal Hemorrhage
Balloon Angioplasty
Jugular Veins
Portal Hypertension
Endoscopy
Ligation
Blood Vessels
Renal Dialysis
Dialysis
Therapeutics

Keywords

  • Bleeding varices
  • Case report
  • Esophagus
  • Proximal esophageal varices
  • Superior vena cava
  • Vascular obstruction

ASJC Scopus subject areas

  • Gastroenterology

Cite this

Bleeding 'downhill' esophageal varices associated with benign superior vena cava obstruction : Case report and literature review. / Loudin, Michael; Anderson, Sharon; Schlansky, Barry.

In: BMC Gastroenterology, Vol. 16, No. 1, 134, 24.10.2016.

Research output: Contribution to journalArticle

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abstract = "Background: Proximal or 'downhill' esophageal varices are a rare cause of upper gastrointestinal hemorrhage. Unlike the much more common distal esophageal varices, which are most commonly a result of portal hypertension, downhill esophageal varices result from vascular obstruction of the superior vena cava (SVC). While SVC obstruction is most commonly secondary to malignant causes, our review of the literature suggests that benign causes of SVC obstruction are the most common cause actual bleeding from downhill varices. Given the alternative pathophysiology of downhill varices, they require a unique approach to management. Variceal band ligation may be used to temporize acute variceal bleeding, and should be applied on the proximal end of the varix. Relief of the underlying SVC obstruction is the cornerstone of definitive treatment of downhill varices. Case presentation: A young woman with a benign superior vena cava stenosis due to a tunneled internal jugular vein dialysis catheter presented with hematemesis and melena. Urgent upper endoscopy revealed multiple 'downhill' esophageal varices with stigmata of recent hemorrhage. As there was no active bleeding, no endoscopic intervention was performed. CT angiography demonstrated stenosis of the SVC surrounding the distal tip of her indwelling hemodialysis catheter. The patient underwent balloon angioplasty of the stenotic SVC segment with resolution of her bleeding and clinical stabilization. Conclusion: Downhill esophageal varices are a distinct entity from the more common distal esophageal varices. Endoscopic therapies have a role in temporizing active variceal bleeding, but relief of the underlying SVC obstruction is the cornerstone of treatment and should be pursued as rapidly as possible. It is unknown why benign, as opposed to malignant, causes of SVC obstruction result in bleeding from downhill varices at such a high rate, despite being a less common etiology of SVC obstruction.",
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