Bleeding Downhill Varices Associated With Central Venous Catheter-Related Thrombosis: An Emphasis on Management

Abstract

Esophageal varices can be uphill or downhill. Downhill varices (DV) occur less frequently and are due to obstruction of the superior vena cava that may lead to downward venous flow via esophageal collaterals towards the portal vein and inferior vena cava. 55 year-old female with a history of non-Hodgkin's lymphoma, ovarian cancer, coronary artery disease s/p stents, Factor V Leiden deficiency, stroke, chronic superior vena cava (SVC) syndrome who was admitted for melena and fatigue x 3 weeks. Currently on aspirin, Plavix and warfarin. She presented with Hemoglobin 6.1 from baseline of 11.6, INR 4.5. Platelets 350. US abdomen showed fatty liver, patent portal vein, no suggestion of veno-occlusive disease, no ascites. CT abdomen pelvis showed diffuse esophageal varices likely from collateral supply due to chronic SVC occlusion, no evidence of liver cirrhosis. EGD showed 3 columns of downhill esophageal varices with high-risk stigmata extending throughout the esophagus 15 - 40 cm. No gastric varices. She has h/o chronic SVC syndrome due to history of thrombosis of subclavian vein from a port placed decades ago. She underwent endovascular stenting few years ago that appears occluded on CT a year ago. This was followed by unsuccessful attempt at endovascular intervention on her chronically occluded stents to right subclavian vein and SVC. Repeat EGD showed 4 columns of small varices, no banding. Followed in GI and hematology clinic & undergoing variceal surveillance. DV contribute only 0.1% of all esophageal variceal bleeding. The most common etiology of bleeding DV is a complication related to a venous catheter. The diagnosis of DV is reached at endoscopy. This is recognized as a separate entity from portal hypertension varices, since both the etiology and clinical management are very different. DV bleed very rarely when compared to uphill varices. Cornerstone of the management is directed to the underlying cause of vascular obstruction (stents or vascular bypass in surgical candidates) that will cure the clinical syndrome and also prevent its recurrence. When all the above measures fail to resolve the obstruction only palliative measures can be applied. Endoscopic treatment options include banding however associated with increased risk of bleeding or perforation in upper esophagus. In general, endoscopic surveillance is recommended; however, the optimal interval is unknown.