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Bleeding non-cirrhotic fundus (“downhill”) varices in a patient on chronic intermittent hemodialysis
European Journal of Internal Medicine 17 (2006) 586 www.elsevier.com/locate/ejim
Letter to the Editor
Bleeding non-cirrhotic fundus (“downhill”) varices in a patient on chronic intermittent hemodialysis J.G. Lutisan a , S. Ploem b , J.G. Zijlstra a,⁎ a
Intensive and Respiratory Care (ICB), University Medical Center Groningen, University of Groningen, P.O. Box 30.001, 9700 RB Groningen, The Netherlands b Department of Radiology, University Medical Center Groningen, University of Groningen, P.O. Box 30.001, 9700 RB Groningen, The Netherlands Received 13 January 2006; received in revised form 7 March 2006; accepted 3 April 2006
Keywords: Downhill varices; Venous access complications
A 50-year-old man on hemodialysis presented with expectoration of blood and chest pain. Pulmonary embolism was excluded by CT-scan. He was admitted to our ICU for gastrointestinal tract endoscopy. Bleeding occurred from an erosive lesion, which was injected with Ethoxy-sclerol®. After an improvement in visibility due to hemostasis, esophageal and fundus varices were seen. Liver function was normal. Echo-duplex showed normal flow in the vena lienalis and the portal vein and no other signs of portal hypertension. In retrospect, the CT-scan provided an explanation for the non-cirrhotic varices. There were extensive collateral chest wall veins. In the early phase, there was already contrast projection in the vena azygos and lienalis. An obstruction in the superior caval vein (SVC) at a point closer to the heart than the insertion of the azygous vein was seen. Blood was shunted through the azygous vein cranio-caudal (“downhill”) along the perioesophageal plexus into the portal circulation. The obstruction was probably the result of thrombosis due to venous catheters for hemodialysis. Downhill varices is a rare condition. When it occurs, it is usually due to thrombosis secondary to central lines or SVC
compression from outside [1,2]. Therapy for bleeding is comparable to that for varices caused by portal hypertension, although experience with bleeding downhill varices is limited and there are some theoretical considerations [2]. Octreotide may be useful because it reduces portal venous pressure and probably the pressure in the varices. However, the blood flow through the collateral blood vessels in downhill varices may increase. A Sengstaken–Blakemore tube obstructs the downhill flow and may increase bleeding. Band ligation is preferably done upstream, but this could hamper an endoscopic approach to the bleeding site in the near future. Sclerotherapy may have some advantages. Dilatation of this stenosis, although initially successful, does not prevent recurrence in the long term [2]. References [1] Glanz S, Koser MW, Dallemand S, Gordon DH. Upper esophageal varices: report of three cases and review of the literature. Am J Gastroenterol 1982;77(3):194–8. [2] Blam ME, Kobrin S, Siegelman ES, Scotiniotis IA. “Downhill” esophageal varices as an iatrogenic complication of upper extremity hemodialysis access. Am J Gastroenterol 2002;97(1):216–8.
⁎ Corresponding author. Tel.: +31 503616161; fax: +31 503613216. E-mail address: [email protected] (J.G. Zijlstra). 0953-6205/$ - see front matter © 2006 International Federation of Internal Medicine. Published by Elsevier B.V. All rights reserved. doi:10.1016/j.ejim.2006.04.016
Letter to the Editor
Bleeding non-cirrhotic fundus (“downhill”) varices in a patient on chronic intermittent hemodialysis J.G. Lutisan a , S. Ploem b , J.G. Zijlstra a,⁎ a
Intensive and Respiratory Care (ICB), University Medical Center Groningen, University of Groningen, P.O. Box 30.001, 9700 RB Groningen, The Netherlands b Department of Radiology, University Medical Center Groningen, University of Groningen, P.O. Box 30.001, 9700 RB Groningen, The Netherlands Received 13 January 2006; received in revised form 7 March 2006; accepted 3 April 2006
Keywords: Downhill varices; Venous access complications
A 50-year-old man on hemodialysis presented with expectoration of blood and chest pain. Pulmonary embolism was excluded by CT-scan. He was admitted to our ICU for gastrointestinal tract endoscopy. Bleeding occurred from an erosive lesion, which was injected with Ethoxy-sclerol®. After an improvement in visibility due to hemostasis, esophageal and fundus varices were seen. Liver function was normal. Echo-duplex showed normal flow in the vena lienalis and the portal vein and no other signs of portal hypertension. In retrospect, the CT-scan provided an explanation for the non-cirrhotic varices. There were extensive collateral chest wall veins. In the early phase, there was already contrast projection in the vena azygos and lienalis. An obstruction in the superior caval vein (SVC) at a point closer to the heart than the insertion of the azygous vein was seen. Blood was shunted through the azygous vein cranio-caudal (“downhill”) along the perioesophageal plexus into the portal circulation. The obstruction was probably the result of thrombosis due to venous catheters for hemodialysis. Downhill varices is a rare condition. When it occurs, it is usually due to thrombosis secondary to central lines or SVC
compression from outside [1,2]. Therapy for bleeding is comparable to that for varices caused by portal hypertension, although experience with bleeding downhill varices is limited and there are some theoretical considerations [2]. Octreotide may be useful because it reduces portal venous pressure and probably the pressure in the varices. However, the blood flow through the collateral blood vessels in downhill varices may increase. A Sengstaken–Blakemore tube obstructs the downhill flow and may increase bleeding. Band ligation is preferably done upstream, but this could hamper an endoscopic approach to the bleeding site in the near future. Sclerotherapy may have some advantages. Dilatation of this stenosis, although initially successful, does not prevent recurrence in the long term [2]. References [1] Glanz S, Koser MW, Dallemand S, Gordon DH. Upper esophageal varices: report of three cases and review of the literature. Am J Gastroenterol 1982;77(3):194–8. [2] Blam ME, Kobrin S, Siegelman ES, Scotiniotis IA. “Downhill” esophageal varices as an iatrogenic complication of upper extremity hemodialysis access. Am J Gastroenterol 2002;97(1):216–8.
⁎ Corresponding author. Tel.: +31 503616161; fax: +31 503613216. E-mail address: [email protected] (J.G. Zijlstra). 0953-6205/$ - see front matter © 2006 International Federation of Internal Medicine. Published by Elsevier B.V. All rights reserved. doi:10.1016/j.ejim.2006.04.016