Hematemesis, a Rare Presentation for Downhill Esophageal Varices

Abstract

Downhill esophageal varices (DEV) are a rare form of esophageal varices associated with superior vena cava obstruction. Obstruction leads to retrograde blood flow through collateral venous channels, including the esophageal venous plexus, to redirect blood flow to the right atrium via the inferior vena cava. This leads to the formation of DEV. It is a rare phenomenon to have gastrointestinal bleeding, especially hematemesis, on a patient’s first presentation with this disease process. We describe such a case here involving a patient with DEV secondary to metastatic renal cell carcinoma presenting with hematemesis.

Idiopathic fibrosing mediastinitis with esophageal varices: A case report

“…Initially, the patient might have variceal bleeding because of azygos vein dilatation. However, when the SVC obstruction is above the level of the azygos vein, varices form in the proximal third of the esophagus, whereas if the obstruction is below or involves the azygos vein, varices form along the entire esophagus [ 10 ]. This is not seen in our case, and it is likely the patient has developed portal gastropathy as the cause of the varices, which was diagnosed five years before admission.…”

Downhill esophageal varices associated with superior vena cava syndrome – A case report

“…A multidisciplinary team is required to determine the best DEV therapy; thus, there are no definitive recommendations regarding DEV management, which typically aims to treat the etiology of SVC obstructions (Yasar & Abut, 2015). When DEV is secondary to obstruction by a neoplasm, the possibility of chemotherapy, radiotherapy, or even surgical resection to reduce venous hypertension should be considered (Van & Singh, 2021). In cases associated with thrombosis or stenosis of the SVC, endovascular therapy, angioplasty with or without a stent, or revascularization surgery should be considered (Berkowitz et al, 2016), with the decision being individualized and shared with the surgical team.…”

“…Endoscopic treatment can be performed with band ligation or sclerotherapy, which is generally restricted to acute bleeding due to the risk of complications associated with fragility of the posterior wall in the upper third of the esophagus and absence of serosa (Van & Singh, 2021). Ligation is preferred, as sclerotherapy is associated with the potential risk of spinal cord infarction (Tavakkoli et al, 2006).…”