"Downhill" varices: A rare cause of esophageal hemorrhage

Areia, Miguel; Romãozinho, José Manuel; Ferreira, Manuela; Amaro, Pedro; Freitas, Diniz

doi:10.4321/s1130-01082006000500006

Cited by 23 publications

(38 citation statements)

References 17 publications

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“…When the obstruction is below or involving the azygous vein, blood returns via the hemiazygos vein, and esophageal and portal veins and may be associated with varices extending throughout the entire esophagus. 2 DEVs have not been reported previously in the veterinary literature. We recently documented, by MDCT angiography, the gastroesophageal and mesenteric varices in a small case series of dogs affected by portal hypertension due to a variety of causes (eg, portal thromboembolism, primary portal vein hypoplasia, intrahepatic portal-venous fistula, and hepatic cirrhosis f ).…”

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confidence: 78%

“…A 6-lead ECG was within normal limits. Arterial blood gas analysis indicated mild respiratory alkalosis (pH, 7.457, reference range, 7.370-7.450; pCO 2 , 29.2 mm Hg, reference range, 30.6-39.1 mm Hg; pO 2 , 90 mm Hg, reference range, 81-105 mm Hg; HCO 3 , 20.9 mmol/L; reference range, 19.1-25 mmol/L). No clinically relevant abnormalities were found on CBC, serum biochemistry, serum protein electrophoresis, or hemostasis profile.…”

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confidence: 99%

“…Varices may be called ''uphill'' or ''downhill'' depending on the direction of venous flow to the central circulation. 1,2 In human patients, uphill varices are more common and usually result from portal hypertension. Downhill esophageal varices (DEVs) serve as collateral branches directing blood flow ''downward,'' either to bypass SVC obstruction via the azygous vein or to drain the superior systemic system to the portal vein when both the SVC and azygous vein are obstructed.…”

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confidence: 99%

“…3 Alternatively, this type of esophageal varices may develop as a result of excessive blood drainage into the esophageal veins caused by systemic venulitis, 4 thyroid disease or intervention, 5 Bechet's disease, 6 Castleman's disease, 7 or pulmonary hypertension. 2 Predominant factors influencing downward extension of esophageal varices are obstruction level and duration. The more distal the increase in blood-flow resistance, the greater the possibility of DEVs developing.…”

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confidence: 99%

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Esophageal Varices Due to a Probable Arteriovenous Communication in a Dog

Bertolini¹,

Lorenzi²,

Ledda³

et al. 2007

J Vet Int Med

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A 6-year-old 40-kg castrated male Samoyed dog was presented for evaluation of chronic remittent lameness of the right forelimb. The dog had a history of polyuria-polydipsia (PU/PD) and lethargy over the previous year. Physical examination was unremarkable except for a grade II systolic murmur at the apex of the heart on the left side. A 6-lead ECG was within normal limits. Arterial blood gas analysis indicated mild respiratory alkalosis (pH, 7.457, reference range, 7.370-7.450 Thoracic radiographs disclosed a generalized increase in the size of the cardiac silhouette and pulmonary vascular enlargement, suggesting pulmonary overcirculation. An ELISA for Dirofilaria immitis antigen was negative. Two-dimensional, M-mode echocardiography a (transducer frequency, 2.0-3.0 MHz) revealed left atrial enlargement, left ventricular eccentric hypertrophy, and impaired systolic function (end-diastolic dimension, 65.7 mm; end-systolic dimension, 44.2 mm; shortening fraction, 32.7%) with normal valves. Spectral and colorflow Doppler examination disclosed mild mitral, aortic, and pulmonic valve insufficiency. Both the tricuspid and the telediastolic pulmonic valvular peak regurgitant jet velocities were increased as follows: 3.26 m/s (normal, #2.5 m/s) and 2.44 m/s (normal, #2.0 m/s), respectively. According to the Bernoulli's equation modification, the systolic pulmonary artery pressure was estimated to be 42.5 mm Hg and the diastolic pulmonary artery pressure was estimated to be 23.9 mm Hg, values consistent with mild pulmonary hypertension.The dog was anesthetized and subjected to radiography of the right forelimb and total body multidetector computed tomography b (MDCT). The radiographs were negative for abnormalities, and synovial fluid examination of the shoulder and stifle joints did not indicate evidence of any inflammatory pathology. MDCT scans of the brain, thorax, and abdomen were obtained. For the thoracic and abdominal scans, the dog was positioned in dorsal recumbency, and we employed the following parameters: helical modality, 120 kV, 200 mA, 0.7-second rotation tube, 0.526 pitch, and 1.2-mm slice thickness. For the brain scan, the dog was positioned in sternal recumbency and the scanner parameters were as follows: axial modality, 120 kV, 310 mA, 2-second rotation tube, 0.625 slice thickness, and 10-mm intervals. For an enhanced series, 2-mL/kg iodixanol c 320 mg I/mL was injected via a 22-gauge catheter into the right cephalic vein at a 3 mL/second infusion rate, through a computed tomography injector system. d The brain and abdominal MDCT scans were normal. However, MDCT of the neck and chest revealed 12 pairs of ribs, an enlarged heart, and enlarged pulmonary vessels. Both of the bronchoesophageal arteries were enlarged and connected with an enormous network of homogeneously enhancing serpentine structures involving the thoracic esophagus (esophageal and paraesophageal varices). The bronchoesophageal vein was extremely dilated (Figs 1, 2). The right azygous and hemizygous veins were normal. The cranial vena ca...

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confidence: 78%

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confidence: 99%

mentioning

confidence: 99%

mentioning

confidence: 99%

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Esophageal Varices Due to a Probable Arteriovenous Communication in a Dog

Bertolini¹,

Lorenzi²,

Ledda³

et al. 2007

J Vet Int Med

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“…To best of our knowledge ours is the 2nd case in literature due to pulmonary artery hypertension, the 1st case was reported by M. Areia et al in 2006. 2 There is another case report from Taiwan where in a young child with infra-cardiac total anomalous pulmonary venous congestion draining in to portal vein developed uphill lower esophageal varices. This case also underlines the role of increased pressure and congestion in a venous channel leading to esophageal varices.…”

Section: Downhill Varices Harwani Et Almentioning

confidence: 99%

Combined Uphill and Downhill Varices as a Consequence of Rheumatic Heart Disease: A Unique Presentation

Harwani

Kumar

Chaudhary

et al. 2014

Journal of Clinical and Experimental Hepatology

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Hemorrhage from downhill varices is a rare manifestation. The etiology of downhill varices is due to superior vena cava obstruction while uphill varices are secondary to portal hypertension. We report a rare case of 55-year-old female with bleeding downhill varices not associated with obstruction or compression of superior vena cava, but was due to severe pulmonary artery hypertension secondary to chronic rheumatic heart disease. ( J CLIN EXP HEPA-TOL 2014;4:63-65) E sophageal varices are classified as downhill or uphill varices. Uphill varices are common, found at the lower end of the esophagus, extend upwards and develop as a consequence of portal hypertension. Downhill varices are rare, found at upper esophagus, extend downwards and usually develop due to superior vena cava obstruction. Very rarely they can develop due to pulmonary artery hypertension. We report a case presenting with upper gastrointestinal bleed from the downhill varices, which was also found to have uphill varices due to portal hypertension. The downhill varices in this patient were due to moderate pulmonary artery hypertension as a consequence of chronic rheumatic heart disease with severe mitral regurgitation, mild mitral stenosis and severe tricuspid regurgitation. CASE REPORTA 55-year-old female was admitted with repeated episodes of hematemesis and melena of 15 days duration. Patient was a diagnosed case of liver cirrhosis. General physical examination revealed pallor, raised jugular venous pressure, pedal edema and icterus. Her pulse was 82/min, regular and a blood pressure of 110/70 mmHg. Her abdomen was distended and shifting dullness was present. Cardiovascular examination revealed apical impulse in 6th intercostal space 2 cm outside mid-clavicular line, grade II parasternal heave, palpable pulmonary artery pulsations and palpable 2nd heart sound at parasternal 2nd left intercostals space, loud P2, opening snap and grade III/VI pansystolic murmur in mitral and tricuspid area. Respiratory and central nervous system examination were normal. On investigation her hemoglobin was 8 g/dL, platelet counts 0.76 lakh/mm 3 , TLC 7200/mm 3 with normal differentials, aspartate aminotransferase (AST) 40 U/L, alanine transferase (ALT) 41 U/L, alkaline phosphatase 150 mg/dL, total bilirubin 2.4 mg/dL with unconjugated fraction of 1.6 mg/dL, total serum proteins 6.2 g/dL, albumin 2.1 g/dL, prothrombin time 20 s, urea 19 mg/dL, creatinine 1 mg/dL, Na 143 meq/l and K was 3.7 meq/L. Her X-ray chest showed cardiomegaly, straightening of left heart border, findings suggestive of right atrium (RA) and left atrium (LA) enlargement, dilated pulmonary artery and superior vena cava (SVC) [ Figure 1]. Her ECG showed normal sinus rhythm with evidence of RA and LA enlargement with evidence of right ventricular hypertrophy (RVH) and left ventricular (LV) volume overload. Her serology was negative for ANA, HBsAg, anti HCV antibodies and HIV. On upper gastrointestinal endoscopy she had large varices 2 columns extending from post cricoid region downwards decreasing...

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Nichtneoplastische Erkrankungen und Barrett-Ösophagus

Langner

Rüschoff

2013

Pathologie

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"Downhill" varices: A rare cause of esophageal hemorrhage

Cited by 23 publications

References 17 publications

Esophageal Varices Due to a Probable Arteriovenous Communication in a Dog

Esophageal Varices Due to a Probable Arteriovenous Communication in a Dog

Combined Uphill and Downhill Varices as a Consequence of Rheumatic Heart Disease: A Unique Presentation

Nichtneoplastische Erkrankungen und Barrett-Ösophagus

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