Post written by Aleem Azal Ali, MBBS, Sonal Jadeja, DO, and Bruno De Souza Ribeiro, MD, from the University of Florida, College of Medicine, Jacksonville, Florida, USA.

This video manuscript describes the case of a 49-year-old man who presented in hypovolemic shock secondary to hematemesis. He had a similar presentation, 2 weeks prior, when EGD revealed esophagitis.

A repeat EGD on this admission revealed Grade III varices in the proximal esophagus with stigmata of recent bleeding. The patient underwent successful variceal band ligation.

Given the unusual findings of downhill varices, the patient underwent a CT angiogram that revealed chronic occlusion of the superior vena cava (SVC) with extensive collateral vessels. The patient reported a history of chronic dialysis vascular access before surgical development of an arteriovenous fistula. The patient underwent successful recanalization and angioplasty of the SVC. He had no further bleeding episodes and was scheduled for repeat surveillance EGD in 6 months.

Endoscopic therapy of nonbleeding downhill varices should be avoided. However, band ligation therapy management of downhill varices at high risk for bleeding, although controversial, can be considered. The patient had 2 presentations characterized by severe hematemesis, and EGD revealed a varix with recognized stigmata of recent bleeding. Therapeutic intervention with banding was successfully performed despite active hemorrhage on manipulation, which is expected when suction is applied in this situation. The patient was deemed high risk for recurrent GI bleeding, and banding was considered fundamental in management.

Downhill varices are seen with an incidence of 0.5% and can easily be missed during endoscopy. During the first emergent EGD, the endoscopist missed the varices. Given their rarity and unusual location, they can easily be missed because the endoscopist may tend to retrieve the endoscope faster when approaching the mid-esophagus. A detailed examination of the proximal and mid-esophagus and slow endoscope retrieval are paramount to avoid mis-visualization of any proximal lesions present.

A high index of suspicion is warranted in patients presenting with hematemesis with a history of repeated cannulation of the superior venous system, especially in patients on hemodialysis. Endoscopic findings of downhill varices should prompt physicians to investigate for an underlying etiology of SVC obstruction, as management of the underlying cause remains the cornerstone of treatment. Endoscopic intervention with variceal banding ligation seems to be an effective temporizing measure in the management of downhill variceal with active bleeding or stigmata of recent bleeding.

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