SHM Converge Scientific Abstract ePoster Gallery-Bleeding Downhill Esophageal Varices: Look Beyond the Liver!

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A 59-year-old man with end-stage renal disease on hemodialysis and hypertension presented with hematemesis and hemoptysis. He was hemodynamically stable and had no signs of chronic liver disease. Labs showed hemoglobin 9.8 g/dL, BUN 50 mg/dL, and creatinine 8.74 mg/dL. CT pulmonary embolism study was negative for PE but revealed esophagitis and chronic superior vena cava (SVC) occlusion with extensive chest wall collaterals and enlarged azygous/hemiazygous veins.<br /><br />Upper endoscopy demonstrated varices in the middle third of the esophagus with stigmata of recent bleeding; six bands were placed. Abdominal ultrasound with Dopplers showed a normal liver and normal portal/hepatic venous flow, making cirrhosis and portal hypertension unlikely. The patient was diagnosed with downhill esophageal variceal bleeding due to SVC obstruction. Interventional radiology performed SVC stenting, and repeat endoscopy one month later showed only trace prominent veins without residual varices.<br /><br />The case highlights that downhill varices are a distinct entity from the more common varices caused by cirrhosis. They occur in the upper or middle esophagus and are associated with venous obstruction, especially SVC occlusion. Important causes include thrombosis related to central venous catheters or pacemaker leads, which is particularly relevant in ESRD patients, as well as mediastinal malignancies such as lung cancer or lymphoma. Definitive treatment targets the underlying venous obstruction, typically with stenting or angioplasty.

Asset Subtitle

Suchit Bhutani

Meta Tag

Author List Emma Weaver, Suchit Bhutani

Category Clinical Vignettes

Concept Downhill Esophageal Varices

Concept Superior Vena Cava Obstruction

Concept Portal Hypertension

Concept Upper Endoscopy

Concept Superior Vena Cava Imaging

Distinguished Finalist

Presenter Organization Thomas Jefferson University Hospital

Presenting Author Suchit Bhutani

Track Adult

Keywords

downhill esophageal varices

superior vena cava occlusion

esophageal variceal bleeding

hemodialysis

end-stage renal disease

SVC stenting

upper endoscopy

chest wall collaterals

azygous vein enlargement

central venous obstruction

Downhill Esophageal Varices

Superior Vena Cava Obstruction

Portal Hypertension

Upper Endoscopy

Superior Vena Cava Imaging