S2161 It's All Downhill From Here: A Case of Proximal Esophageal Varices in a Patient With SARS-CoV2/COVID-19 Infection

Abstract

INTRODUCTION: We present a case of proximal esophageal varices in a patient with COVID-19 infection. CASE DESCRIPTION/METHODS: A 79-year-old male presented with right neck pain after recent hospitalization for COVID-19 complicated by acute renal failure requiring hemodialysis and melena which was medically managed. On arrival, he was febrile (100.4F) and tachycardic (HR 112). Physical exam noted tenderness along the right sternocleidomastoid muscle. Labs were notable for hemoglobin 8.2 g/dL, platelets 244 (103/µL), D-dimer 2,613 (ng/mL-previously 24,780), fibrinogen 490 (mg/dL-previously 1,190). Ultrasound of the neck revealed a thrombus in the right internal jugular vein in the location of his dialysis catheter. Upper endoscopy was pursued given history of melena and need for anticoagulation. Endoscopy revealed columns of non-bleeding, grade II esophageal varices with no high-risk stigmata in the proximal esophagus. A subsequent MRI of the neck showed occlusive thrombus involving the entirety of the right internal jugular vein with likely extension into superior vena cava (SVC). The dialysis catheter was removed and anticoagulation was initiated. DISCUSSION: Proximal or “downhill” esophageal varices are rare and associated with SVC occlusion. Obstruction at the SVC increases pressure in collaterals that drain the proximal and mid esophagus, resulting in development of proximal esophageal varices. SVC obstruction is most commonly caused by mediastinal malignancies but cases of catheter-induced thromboses have been reported.1 Treating proximal esophageal varices requires relieving the underlying SVC obstruction. Bleeding from proximal esophageal varices is rare, but could result in significant consequences.1 In the case presented, thrombosis was likely caused by hypercoagulability from COVID-19 in the presence of a dialysis catheter. Emerging literature has described COVID-19 hypercoagulability, and some have recommended escalating inpatient thromboprophylaxis regimens and considering continuation after discharge.2 Though a rare phenomenon, downhill varices may be encountered more frequently as the COVID-19 pandemic continues and provider awareness could lead to improved patient outcomes.Figure 1.: Image 1: MRI of the neck in coronal view revealing occlusion of the entire right internal jugular vein.Figure 2.: Image 2: Upper gastrointestinal endoscopy view of non-bleeding, grade II varices in the proximal esophagus.