“Downhill” Esophageal Varices due to Dialysis Catheter-Induced Superior Vena Caval Occlusion: A Rare Cause of Upper Gastrointestinal Bleeding

Abstract

“Downhill” varices are a rare cause of acute upper gastrointestinal bleeding. Rarely these varices are reported in patients receiving hemodialysis as a complication of chronic dialysis vascular access. We present a case of acute upper gastrointestinal bleeding in an individual with end-stage renal disease receiving hemodialysis. Esophagogastroduodenoscopy revealed “downhill” varices in the upper third of the esophagus without any active bleeding at the time of the procedure. An angiogram was performed disclosing superior vena caval occlusion, which was treated with balloon angioplasty. Gastroenterologists should have a high index of suspicion for these rare “downhill” varices when dealing with acute upper gastrointestinal bleeding in patients receiving hemodialysis and manage it appropriately using endoscopic, radiological, and surgical interventions.

Evidence‐based Review of Gastrointestinal Bleeding in the Chronic Kidney Disease Patient

“…Gastric varices often coincide with esophageal varices, but can occur in isolation as a result of ‘sinistral’ or left sided portal hypertension due to splenic vein thrombosis; pancreatitis, pancreatic cancer, and trauma are the most common cause of splenic vein thrombosis. Patients with central vein dialysis catheters can develop esophageal varices in the setting of catheter related venous occlusion . These so‐called ‘downhill’ varices are located in the proximal esophagus and are a complication of dialysis access because obstruction of the superior vena cava causes blood diversion to collaterals and thus varices form in the esophagus.…”

A Rare but Reversible Cause of Hematemesis: “Downhill” Esophageal Varices

“…Currently there are no definitive recommendations on screening and management of “downhill” varices. Hemostasis from variceal bleeding is often achieved with endoscopic local intervention such as banding and sclerotherapy [ 1 , 2 , 18 ]. The principle and definitive treatment is to relieve obstruction and revascularize SVC.…”

“…The most common type, “uphill,” esophageal varices are caused by portal vein hypertension with subsequent collateral, decompressive flow. “Downhill” varices are rare dilated veins resulting from obstruction of the superior vena cava (SVC) leading to redirected blood flow to collateral system [ 1 ]. “Downhill” esophageal varices account for 0.4–11% of esophageal varices but less than 0.1% of patients present with hematemesis [ 2 – 4 ].…”

Uphill or downhill bleeding?

“…1 Development is often due to extrinsic processes including superior vena cava obstruction and mediastinal masses. [2][3][4] Thyroid goitre as a cause has been reported but is uncommon. 1 A variety of attempted treatment options for downhill variceal haemorrhage have been reviewed, 1 including band-ligation and sclerotherapy.…”