Proximal Esophageal Varices: A Rare Yet Treatable Cause of Hemorrhage

Diagnosis and Management of Esophagogastric Varices

Acute variceal bleeding (AVB) is a potentially fatal complication of clinically significant portal hypertension and is one of the most common causes of acute upper gastrointestinal bleeding. Thus, esophagogastric varices represent a major economic and population health issue. Patients with advanced chronic liver disease typically undergo an upper endoscopy to screen for esophagogastric varices. However, upper endoscopy is not recommended for patients with liver stiffness < 20 KPa and platelet count > 150 × 10⁹/L as there is a low probability of high-risk varices. Patients with high-risk varices should receive primary prophylaxis with either nonselective beta-blockers or endoscopic band ligation. In cases of AVB, patients should receive upper endoscopy within 12 h after resuscitation and hemodynamic stability, whereas endoscopy should be performed as soon as possible if patients are unstable. In cases of suspected variceal bleeding, starting vasoactive therapy as soon as possible in combination with endoscopic treatment is recommended. On the other hand, in cases of uncontrolled bleeding, balloon tamponade or self-expandable metal stents can be used as a bridge to more definitive therapy such as transjugular intrahepatic portosystemic shunt. This article aims to offer a comprehensive review of recommendations from international guidelines as well as recent updates on the management of esophagogastric varices.

Downhill esophageal varices: a systematic review of the case reports

Aim: The etiologies, presentation, and management of downhill varices in the era of modern medicine are relatively under-explored and mostly limited to case reports or case series. Methods: Published case reports/series of patients ≥ 18 years old with proven/probable downhill esophageal varices were searched on Ovid MEDLINE and Ovid EMBASE for all published cases up to January 2021. Results: The mean age was 50.9 (standard deviation ± 17.6) years old for all downhill variceal cases. End-stage renal disease was the most common comorbidity (43.9%), followed by thyroid disease (12.2%), Behçet’s disease (9.8%), and pulmonary hypertension (7.3%). Dialysis catheters, central venous grafts, or additional catheters were additional risk factors (51.2%). Variceal bleeding presenting as hematemesis, melena, or both was the most common presenting symptom (80.5%). Conclusions: Dialysis catheter-associated superior vena cava obstruction resulted in an increased risk of downhill varices. Other causes include thyroid malignancies, pulmonary hypertension, and Behçet’s disease.

Endoscopic Treatment of Esophageal Varices

Acute variceal bleeding is a complication of portal hypertension, usually due to cirrhosis, with high morbidity and mortality. There are 3 scenarios for endoscopic treatment of esophageal varices: prevention of first variceal bleed, treatment of active variceal bleed, and prevention of rebleeding. Patients with cirrhosis should be screened for esophageal varices. Recommended endoscopic therapy for acute variceal bleeding is endoscopic variceal banding. Although banding is the first-choice treatment, sclerotherapy may have a role. Treatment with Sengstaken-Blakemore tube or self-expanding covered metallic esophageal stent can be used for acute variceal bleeding refractory to standard pharmacologic and endoscopic therapy.

Hematemesis, a Rare Presentation for Downhill Esophageal Varices

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.

Downhill esophageal varices: a therapeutic dilemma

Esophageal varices can cause life-threatening complications and are most often a sequela of liver disease. Although a rare cause of gastrointestinal bleeding, downhill variceal bleeding secondary to superior vena cava (SVC) obstruction should be considered in the differential diagnosis for patients with upper gastrointestinal hemorrhage. We discuss two such cases of downhill esophageal varices presenting with hematemesis in patients with end stage renal disease and no history of cirrhosis. These varices were thought to be secondary to SVC occlusion caused by complications from previous dialysis catheters. However, their difficult anatomy posed a significant challenge to the therapeutic interventions.