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Case Reports in Critical Care
Volume 2016 (2016), Article ID 2370109, 4 pages
Case Report

A Rare but Reversible Cause of Hematemesis: “Downhill” Esophageal Varices

1Division of Pulmonary, Critical Care, and Sleep Medicine, University of California, Davis, Suite #3400, 4150 V Street, Sacramento, CA 95817, USA
2Department of Internal Medicine, University of California, Davis, Sacramento, USA
3VA Northern California Health Care System, Mather, USA

Received 12 December 2015; Accepted 1 February 2016

Academic Editor: Kurt Lenz

Copyright © 2016 Lam-Phuong Nguyen et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.


“Downhill” varices are a rare cause of acute upper gastrointestinal bleeding and are generally due to obstruction of the superior vena cava (SVC). Often these cases of “downhill” varices are missed diagnoses as portal hypertension but fail to improve with medical treatment to reduce portal pressure. We report a similar case where recurrent variceal bleeding was initially diagnosed as portal hypertension but later found to have SVC thrombosis presenting with recurrent hematemesis. A 39-year-old female with history of end-stage renal disease presented with recurrent hematemesis. Esophagogastroduodenoscopy (EGD) revealed multiple varices. Banding and sclerotherapy were performed. Extensive evaluation did not show overt portal hypertension or cirrhosis. Due to ongoing bleeding requiring resuscitation, she underwent internal jugular (IJ) and SVC venogram in preparation for transjugular intrahepatic portosystemic shunt (TIPS), which demonstrated complete IJ and SVC occlusion. She underwent balloon angioplasty with stent placement across SVC occlusion with complete resolution of her varices and resolved hematemesis. “Downhill” varices are extremely rare, though previously well described. Frequently, patients are misdiagnosed with underlying liver disease. High index of suspicion and investigation of alternative causes of varices is prudent in those without underlying liver diseases. Prompt diagnosis and appropriate intervention can significantly improve morbidity and mortality.