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Formation of downhill esophageal varices as a rare but serious complication of hemodialysis access: a case report and comprehensive literature review

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Abstract

Background

Proximal or “downhill” esophageal varices are a rare complication of superior vena caval (SVC) obstruction. Few reports describe downhill varices in dialysis patients with catheter-related SVC occlusion.

Methods

We studied a case of downhill esophageal varices in a dialysis patient from our center and reviewed the published literature on presentation, evaluation and treatment in other dialysis patients (MEDLINE database search).

Results

Including our current case, we identified eight reports of dialysis patients with downhill varices. All cases were recognized after presentation with gastrointestinal bleeding, in contrast to low reported bleeding rates of downhill varices in non-dialysis patients. Localized edema and superficial venous engorgement (signs of SVC occlusion) were each observed in four of eight patients. The duration of hemodialysis dependence ranged from 2.5 to 23 years, and dialysis access history included multiple central venous catheters when described (seven cases). Central venous imaging by direct, magnetic resonance or computerized tomographic venography documented SVC stenosis in all cases. Management included percutaneous transluminal angioplasty of the SVC with or without stenting in five of eight patients, three of whom developed restenosis during observation. Successful surgical venous bypass was performed in one patient after failed percutaneous venoplasty. Varices were treated with band ligation in four of eight cases without reported complications.

Conclusions

Although rare, downhill esophageal varices should be considered in the differential diagnosis of upper gastrointestinal hemorrhage in dialysis patients exposed to central venous catheters. Diagnosis should prompt radiographic evaluation of SVC patency. Treatment requires timely and coordinated care by specialists in endovascular interventions and gastrointestinal endoscopy.

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Acknowledgments

Dr. Lentine receives support from a grant from the National Institute of Diabetes Digestive and Kidney Diseases (NIDDK), K08-DK073036. An abstract describing a portion of this work was presented at the American Society of Nephrology 38th Annual Renal Week Meeting on 11 November 2005 in Philadelphia, PA.

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Authors and Affiliations

  1. Department of Internal Medicine, Saint Louis University School of Medicine, St. Louis, MO, USA

    Fadi A. Hussein

  2. Division of Nephrology, Saint Louis University School of Medicine, St. Louis, MO, USA

    Neghae Mawla, Kevin J. Martin & Krista L. Lentine

  3. Division of Gastroenterology, Saint Louis University School of Medicine, St. Louis, MO, USA

    Alex S. Befeler

  4. Center for Outcomes Research, Saint Louis University, Salus Center 2nd Floor, 3545 Lafayette Avenue, St. Louis, MO, 63104, USA

    Krista L. Lentine

Authors
  1. Fadi A. Hussein
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  2. Neghae Mawla
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  3. Alex S. Befeler
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  4. Kevin J. Martin
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  5. Krista L. Lentine
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Corresponding author

Correspondence to Krista L. Lentine.

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Hussein, F.A., Mawla, N., Befeler, A.S. et al. Formation of downhill esophageal varices as a rare but serious complication of hemodialysis access: a case report and comprehensive literature review. Clin Exp Nephrol 12, 407–415 (2008). https://doi.org/10.1007/s10157-008-0055-4

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  • DOI: https://doi.org/10.1007/s10157-008-0055-4

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