Jeremy Van, DO
Chicago, Illinois
Jeremy Van, DO, Shubha Singh, MD
Rush University Medical Center, Chicago, IL
Introduction: Downhill esophageal varices (DEV) are a rare form of varices associated with superior vena cava (SVC) obstruction. Obstruction leads to retrograde blood flow through collateral channels, including the esophageal venous plexus. This case describes a patient with hematemesis due to DEV from an enlarged paratracheal lymph node (PLN) secondary to metastatic disease (mets) from renal cell carcinoma (RCC).
Case Description/Methods: A 65 year old male with past medical history of RCC s/p right nephrectomy with mets to the brain and mediastinum presented with a one day history of hematemesis and significant drop in hemoglobin. Esophagogastroduodenoscopy (EGD) was remarkable for large DEV in the proximal to mid-esophagus with white nipple sign. Band ligation was deferred given no active bleeding. Liver function tests were normal, vascular duplex of the abdomen was unremarkable, and CT chest with IV contrast showed extrinsic compression of the distal brachiocephalic veins (BV) and proximal SVC from a 4.6 cm necrotic right PLN. Radiotherapy was used to decrease the lymph node size and resultant extrinsic venous compression.
Discussion: DEV are a rare entity compared to uphill varices (UV) found in the distal esophagus due to portal hypertension. Hematemesis is more common with UV because of their location in the superficial sub-epithelium and increased acid exposure. DEV are located proximally in the submucosa, have more protection against acid, and have less than a 0.1% chance of causing hematemesis. After diagnosis with EGD, there are no clear guidelines on management. In this patient, banding was deferred given high risk of bleeding and perforation due to weakness in the proximal esophageal posterior wall and lack of serosa. After diagnosis on EGD, CT chest revealed the underlying cause of bleeding: SVC obstruction. The gold standard imaging study is direct venography but CT chest is an adequate alternative study. No surgical intervention was performed given the precarious nature and location of the lymph node and stenting of the SVC was deferred given the risk for re-bleed if placed on anticoagulation. Thus, radiotherapy was ultimately determined to be the next best step to decrease the extrinsic compression of the SVC from the lymph node.
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Gebreselassie A, Awan A, Yaqoob H, Laiyemo A. Superior Vena Cava Obstruction: A Rare Cause of Recurrent Esophageal Variceal Bleeding. 2018 Feb 26. 2226.
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Citation: Jeremy Van, DO, Shubha Singh, MD. P1343 - A CASE OF DOWNHILL ESOPHAGEAL VARICES SECONDARY TO METASTATIC DISEASE FROM RENAL CELL CARCINOMA AND RESULTANT SUPERIOR VENA CAVA SYNDROME. Program No. P1343. ACG 2019 Annual Scientific Meeting Abstracts. San Antonio, Texas: American College of Gastroenterology.