Downhill esophageal varices, classically defined as those that develop in the upper region of the esophagus, are less common than the “uphill” type, which are usually produced by portal hypertension. Causes of downhill varices include lung or thyroid carcinoma, mediastinal fibrosis, SVC ligation, metastatic carcinoma, mediastinal mass of unknown origin, venulitis, and muscular constriction of abnormal extensions of posterior hypopharyngeal veins. Though SVC stenosis or obstruction is a known complication of hemodialysis catheters, Pop and Cutler were the first to describe downhill varices as a specific end result of hemodialysis access. As opposed to uphill varices due to portal hypertension, the downhill varices are caused due to systemic venous obstruction above the diaphragm where the shunted blood flows in parallel with the aorta or downhill. The location and extent of such varices depends on the anatomic site and the duration of venous obstruction.