The Pandora's Box of Downhill Varices

A 67-year-old man presented with complaints of gradually progressive difficulty swallowing for 1 month. The swallowing difficulty was more for solid than for liquid. Over the last 2 weeks, the patient also complained of chest pain, anorexia, and weight loss. His general physical examination and basic laboratory investigation were normal. His esophagogastroduodenoscopy revealed downhill varices with luminal narrowing due to extrinsic impression extending from 25 to 29 cm from incisor with normal overlying mucosa ([Fig. 1]). His contrast-enhanced computed tomography of the chest revealed a heterogeneously enhancing lesion in the superior segment of the right lower lobe with mediastinal lymphadenopathy with central necrotic area near the carinal bifurcation encasing the esophagus with significant luminal compromise causing mild upstream dilatation of esophagus ([Fig. 2]). Ultrasound-guided biopsy from the lung lesion was done and histopathological examination revealed it to be adenocarcinoma of the lung.

Fig. 1 Esophagogastroduodenoscopy image showing large varices in the proximal and middle third of the esophagus with no bleeding stigmata (yellow arrow).

Fig. 2 (A) Sagittal section of computed tomography showing mediastinal lymphadenopathy in prevertebral region (yellow arrow). (B) Cross-sectional computed tomography image showing heterogeneously enhancing lung lesion in the superior segment of the right lower lobe (orange arrow) with necrotic mediastinal lymphadenopathy at the level of carinal bifurcation (yellow arrow).

Practical Implications for Endoscopists

• Downhill esophageal varices are frequently associated with superior vena cava (SVC) obstruction and are named based on their cephalad-to-caudal direction of blood flow.

• Typically located in the upper third or middle third of the esophagus,[1] these varices arise from causes such as upper mediastinal tumors, most commonly lung, thyroid, and metastatic tumors. Other contributing factors include mediastinal fibrosis, surgical ligation of the SVC, and complex Central Venous Catheter (CVC) placement.[2]

• As the blood flow in the intrinsic venous structure of the esophagus is intricately connected to various mediastinal and abdominal tissues through a multitude of veins, pathologic conditions affecting these areas can also have implications for the venous plexus of the esophagus.[3]

 

MissingLinkText

 

MissingLinkText

Conflict of Interest

None declared.

Patient's Consent

The patient provided informed consent to publish the included information.

• References

• 1 Chakinala RC, Kumar A, Barsa JE. et al. Downhill esophageal varices: a therapeutic dilemma. Ann Transl Med 2018; 6 (23) 463
• 2 Nemat H, Gupta V, Abbasi U, Gorantla S, David J, Cowan J, Culpepper-Morgan J. A case of downhill esophageal varices: a rare cause of upper gastrointestinal bleeding. Am J Gastroenterol 2010; 105: S378-S379
• 3 Pelot D, Reynolds JC. Anatomy, anomalies, and physiology of the esophagus. Bockus Gastroenterol 1995; 1: 397-411

Publication History

Article published online:
06 November 2024