Are Downhill Varices an Overlooked Entity of Upper Gastrointestinal Bleedings?

Abstract

Aim Downhill varices are not so safe as thought and can lead to life-threating or mortal bleeding complication, even if rare. In order to draw attention to this topic, we analysed 129 patients. Materials and Methods We evaluated the electronic endoscopy data records of all patients undergoing upper gastrointestinal endoscopy over a nine-year period from January 2004 till December 2012, within a retrospective approach. The primary endpoints, incidence, causes, kind of resulting upper gastrointestinal bleeding, and the severity of the bleeding were evaluated. Secondary endpoints were the evaluation of the size of downhill varices and a comparison of the risk of bleeding between downhill varices and uphill varices. Results Downhill varices were identified, described, and/or documented in 129 patients of 25,680 upper gastrointestinal endoscopies. 26 patients had central venous catheter or port implantation, 22 patients had a history of an implantation of a cardiac pacemaker, 7 patients had severe pulmonary artery embolism, and 4 patients had severe chronic obstructive pulmonary disease. Two patients had mediastinal tumors, and one patient had a large retrosternal goiter as a possible cause of the vena cava syndrome. Altogether, 62 patients were related to a vena cava superior syndrome; 67 were not. Conclusions Downhill varices can be seen with an incidence of 0.5%. Therapeutic means are the banding therapy as a safe and effective option. Severe bleedings associated with downhill varices can be mortal. Severe forms of downhill varices should be examined in relation to the origin in order to start a specific therapy.

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

“…DEV is an uncommon condition, with little data on its prevalence and etiology; therefore, current publications are limited to case reports (Ayvaz et al, 2018). DEVs have a low incidence, corresponding to 0.5% of patients undergoing UDE, and are responsible for 0.4% to 10% of variceal upper gastrointestinal bleeding cases (Ali A.A et al, 2021).…”

An Unusual Cause of Esophageal Varices

“…Of patients with pacemaker implantation, 1%-3% develop SVC obstruction and 30% of patients with SVC obstruction develop DEV. 3 It is estimated that around 0.1% of all variceal bleeds are from DEVs. 2 Banding of downhill varices is typically not performed unless there is active gastrointestinal bleeding, in which case banding or sclerotherapy should be used only to temporize variceal bleeding.…”

“…Ultimately, the management on downhill varices is managing the underlying cause of the SVC obstruction, which includes angioplasty with stent placement or the surgical management of SVC obstruction. 2,3 Clinicians should be aware of alternative etiologies of esophageal varices, as the management of DEV is a multidisciplinary approach to remedy the underlying cause of SVC obstruction.…”

Downhill esophageal varices: a systematic review of the case reports

“…In contrast, the thoracic esophagus drains via the azygos vein, the hemiazygos vein, and the bronchial veins, entering the superior vena cava (SVC). The venous drainage of the lower third of the esophagus is via the portal vein [2,3]. An increase in portal hypertension causes the diversion of blood from the portal system to the SVC via portosystemic anastomosis resulting in "uphill" varices [4].…”

“…Esophageal veins, which are typically not visible, can become visible due to obstructions in portal blood flow or of the SVC, leading to dilation of intramural and paraesophageal veins. They work as a collateral circulation between the portal vein, the azygos system, and the vena cava system [2,3]. Augmented SVC pressures were thought to be the only cause for downhill varices, but recently cases have been reported due to non-obstructive SVC .…”