Critical Care |

A Rare but Reversible Causes of Hematemesis: "Downhill Esophageal Varices" FREE TO VIEW

Lam Phuong Nguyen, DO; Narin Sriratanaviriyakul, MD; Christian Sandrock, MD
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UC Davis Medical Center and VA Mather, Sacramento, CA

Chest. 2014;146(4_MeetingAbstracts):259A. doi:10.1378/chest.1991547
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SESSION TITLE: Critical Care Case Report Posters II

SESSION TYPE: Affiliate Case Report Poster

PRESENTED ON: Tuesday, October 28, 2014 at 01:30 PM - 02:30 PM

INTRODUCTION: There are 3 different types of esophageal varices, classified based on direction of venous flow: “uphill”, “downhill” or idiopathic. The most common type, uphill esophageal varices are caused by portal vein hypertension with subsequent collateral, decompressive flow. Downhill varices are more rare and due to obstruction of the superior vena cava (SVC). Often these cases of “downhill varices” are initially diagnoses with portal hypertension and liver disease, only to not improve with repeated treatment.

CASE PRESENTATION: We report a similar case where recurrent variceal bleeding was initially diagnosed as liver failure but later found to have SVC thrombosis. A 39 year-old female with history of end-stage-renal disease on dialysis presented with recurrent hematemesis. Esophagogastroduodenoscopy (EGD) revealed multiple varices and banding and sclerotherapy was performed (figure 1a). Extensive evaluation did not show overt portal hypertension or cirrhosis. She had ongoing bleeding requiring resuscitation and underwent internal jugular (IJ) and SVC venogram in preparation for transjugular intrahepatic portosystemic shunt (TIPS), demonstrating complete IJ and SVC occlusion. She underwent balloon angioplasty with stent placement across SVC occlusion. Subsequent EGD two weeks later showed complete resolution of her varices (figure 1b).

DISCUSSION: Downhill varices is extremely rare, though previously well described. They are either located in the upper esophagus or may involve the entire esophagus depending on the level of SVC obstruction. There are no definitive recommendations on management of downhill varices. Hemostasis from variceal bleeding is often achieved with endoscopic local intervention. In the setting of uphill varices, long term treatment is directed toward controlling the portal vein hypertension. However in the case of downhill varices, principle treatment goal is to relieve obstruction and revascularize SVC.

CONCLUSIONS: Frequently, patients are considered to have underlying liver disease and even are referred for TIPS or additional procedures that will not treat the underlying cause, as with this case. High index of suspicion and investigation of alternative causes of varices is prudent in those without underlying liver diseases. Prompt diagnosis and appropriate intervention can significantly improved outcome.

Reference #1: Leggio, L et al. Superior vena cava thrombosis treated by angioplasty and stenting in a cirrhotic patient with periotoneovenous shunt. Ann Thorac Cardiovasc Surg 2008: 14: 60-62

DISCLOSURE: The following authors have nothing to disclose: Lam Phuong Nguyen, Narin Sriratanaviriyakul, Christian Sandrock

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