“Downhill” Esophageal Varices due to Dialysis Catheter-Induced Superior Vena Caval Occlusion: A Rare Cause of Upper Gastrointestinal Bleeding

“Downhill” varices are a rare cause of acute upper gastrointestinal bleeding. Rarely these varices are reported in patients receiving hemodialysis as a complication of chronic dialysis vascular access. We present a case of acute upper gastrointestinal bleeding in an individual with end-stage renal disease receiving hemodialysis. Esophagogastroduodenoscopy revealed “downhill” varices in the upper third of the esophagus without any active bleeding at the time of the procedure. An angiogram was performed disclosing superior vena caval occlusion, which was treated with balloon angioplasty. Gastroenterologists should have a high index of suspicion for these rare “downhill” varices when dealing with acute upper gastrointestinal bleeding in patients receiving hemodialysis and manage it appropriately using endoscopic, radiological, and surgical interventions. 1. Introduction “Downhill” varices are a rare cause of acute upper gastrointestinal bleeding. These varices have been reported in association with superior vena caval (SVC) obstruction secondary to extrinsic compression from tumors or venous thrombosis. Very rarely the SVC obstruction has been reported in literature in individuals with end-stage renal disease (ESRD) as a complication of chronic dialysis access [1–8]. We present a case of acute upper gastrointestinal bleeding in an individual with ESRD receiving hemodialysis. He previously underwent multiple angioplasties due to malfunctioning dialysis access resulting in SVC occlusion. 2. Case Presentation A 48-year-old African American man presented to our emergency department (ED) with hematemesis and melena. Associated symptoms included dizziness and generalized weakness. He denied any abdominal pain or previous episodes of gastrointestinal bleeding. He also denied prior endoscopic work-up. His medical history included ESRD on maintenance hemodialysis, seizure disorder, dyslipidemia, and hypertension. His surgical history included repair of abdominal aortic aneurysm, aortic valve replacement, and construction of arteriovenous (AV) fistula multiple times for dialysis access. Patient was receiving Coumadin for his aortic valve replacement; however, patient was noncompliant with Coumadin for few days prior to his admission. He denied the use of tobacco, alcohol, or recreational drugs. Physical examination on the patient revealed hypotension with systolic blood pressure of 80 millimeters of mercury. Patient was in mild distress with clear mentation and was able to provide clear history. His abdominal examination was normal with no distension or tenderness.