AN UNUSUAL CAUSE OF UPPER GI BLEEDING

Abstract

Introduction: Distal esophageal varices are a common cause of upper gastrointestinal bleeding and a known complication of portal hypertension. Proximal esophageal varices or “downhill” varices rarely cause clinically apparent bleeding. These varices can be the result of superior vena cava obstruction. Case Report: A 49 year-old man was admitted with a 3 day history of 4–5 loose, black stools and new onset dizziness. He denied alcohol and NSAID usage except for an 81-mg aspirin QD. His past medical history was significant for previous histoplasmosis infection. The physical exam was significant for orthostatic hypotension and tachycardia. Pertinent laboratory values included a hgb of 10.3 g/dl and hct 30.4 g/dl down from a baseline hgb of 12 g/dl. His BUN was 39 with a creatinine of 0.9 with normal PT, INR, and platelets. After volume resuscitation, the patient underwent an EGD that demonstrated four columns of grade II-III esophageal varices in the proximal 1/3 of the esophagus with red whale signs. No other significant lesions were seen on the EGD. A CT scan of the chest revealed superior vena cava occlusion with calcifications and multiple collateral vessels throughout the anterior chest wall. A CT scan from 10 years earlier was obtained from an outside hospital which documented superior vena cava occlusion and had been consistent with fibrosing mediastinitis. Medical records indicated he had been treated for histoplasmosis and also treated with heparin and anti-inflammatory medication for several weeks. Given the fact that the current bleeding spontaneously stopped, the decision was made for conservative therapy. The patient did well and had no further bleeding in the 4–5 months after discharge. Conclusion: Although extremely rare, several case reports have documented various etiologies for proximal esophageal varices. This is the first case report of histoplasmosis induced fibrosing mediastinitis that caused upper GI bleeding. This resulting inflammation interrupted the superior vena cava flow causing the formation of downhill varices. Proximal esophageal varices bleed less often than distal varices because they are not associated with the coagulation disturbances that accompany portal hypertension and distal varices. They are farther away from the GE junction, thus less exposed to reflux. Also, the downhill varices distend into the submucosa whereas distal varices are located in the subepithelium.