WHEN CATHETERIZATIONS GO "DOWNHILL"

Abstract

SESSION TITLE: Medical Student/Resident Signs and Symptoms of Chest Disease Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Downhill esophageal varices (DEV) are a rare cause of upper gastrointestinal bleeding secondary to superior vena cava (SVC) obstruction. While uphill varices from portal hypertension are commonly seen in practice, there are no current guidelines on the screening and management of downhill varices due to their unique pathophysiology. Here we present an underreported case of DEV from SVC obstruction after long-standing catheter placement. CASE PRESENTATION: A 65-year-old male patient presented to clinic with dysphagia. On upper endoscopy, an isolated upper esophageal varix was noted without varices in the lower esophagus. Chest CT revealed SVC stenosis close to the RA junction. Systemic collaterals were noted via branching to the intercostal and inferior phrenic vein. No significant stenosis of the SVC was present post-ballooning. Patient history indicated a long-term right-sided Port-A-Cath that had been removed a couple months prior due to a thrombus. DISCUSSION: DEV are found in the upper 2/3 of the esophagus as a result of SVC obstruction, from causes like thrombus, thyroid tumors, etc. Central venous catheters, typically in patients with end-stage renal disease, are an accepted cause of DEV from SVC obstruction. Mechanistically, SVC obstruction follows turbulent blood flow, endothelial injury, and thrombosis. This produces varices via dilation of venous drainage, specifically the azygous and hemiazygous systems. Obstruction precedes retrograde blood flow through collateral channels to the IVC. Varices form in the upper third of the esophagus if the stenosis is above the azygous vein and form in the entire esophagus if the stenosis is below or involves the azygous vein. Treatment focuses on the underlying cause of the SVC narrowing. Depending on the specific anatomy of the DEV, options include stenting, thrombolysis, angioplasty, tumor resection, variceal band ligation, or open surgery. In our case, a diagnosis of DEV rather than uphill varices was supported by the isolated upper varices without any lower varix presentation found on endoscopy. Further chest CT displayed SVC stenosis and systemic collaterals. Diagnosis of DEV was confirmed given the patient’s recent history of long-term right sided Port-A-Cath use. CONCLUSIONS: In patients with long-standing catheterizations, clinicians should be cognizant of potential DEV given risk of rupture and progression to hematemesis or hemoptysis. Due to the commonality of dilated collaterals on imaging, prior patient history indicative of SVC obstruction is critical in supporting diagnosis of DEV. The diverse pathophysiology & anatomy involved necessitates DEV treatment focus on the underlying source of the SVC obstruction. Reference #1: Chakinala, R. C., … Aronow, W. S. (2018). Downhill esophageal varices: a therapeutic dilemma. Annals of translational medicine, 6(23), 463. doi:10.21037/atm.2018.11.13 Reference #2: Berkowitz, J. C., Bhusal, S., Desai, D., Cerulli, M. A., & Inamdar, S. (2016). Downhill Esophageal Varices Associated With Central Venous Catheter-Related Thrombosis Managed With Endoscopic and Surgical Therapy. ACG case reports journal, 3(4), e102. doi:10.14309/crj.2016.75 Reference #3: Harwani, Y. P., Kumar, A., Chaudhary, A., Kumar, M., Choudeswari, P. R., Kankanala, V. V., … Tripathi, A. (2014). Combined uphill and downhill varices as a consequence of rheumatic heart disease: a unique presentation. Journal of clinical and experimental hepatology, 4(1), 63–65. doi:10.1016/j.jceh.2013.10.003 DISCLOSURES: No relevant relationships by jayanth keshavamurthy, source=Web Response No relevant relationships by Rohit Munagala, source=Web Response No relevant relationships by Moonkyung Schubert, source=Web Response