P2475 - A Rare Case of Upper Gastrointestinal Bleeding: Downhill Esophageal Varices Due to Chronic Deep Vein Thrombosis of Right Upper Extremity

Shreel H. Patel, MD¹, Sushreyta Rose, DO², James Gnecco, DO², Sylvia Keiser, DO², Matthew Schwartz, MD³, Nirav B. Patel, MS⁴, Hareesh Gundlapalli, MD⁵, Jawairia Memon, MD^2
1University of Texas Rio Grande Valley - Knapp Medical Center, Weslaco, TX; ²UTHSCSA, San Antonio, TX; ³Brooke Army Medical Center, San Antonio, TX; ⁴GCS Medical College, Hospital and Research Centre, Weslaco, TX; ⁵University of New Mexico, San Antonio, TX

Introduction: Upper gastrointestinal bleeding presents with hematemesis, melena or in 5 to 10 % cases UGIB can present can as hematochezia. UGIB is defined as any bleeding proximal to the ligament of Treitz. Main causes are peptic ulcer disease, erosive gastritis or esophagitis, distal esophageal varices, Mallory Weiss tear, portal hypertensive gastropathy and mass lesions. Therefore, we present a rare case of the UGIB due to downhill esophageal varices due to the chronic DVT of right upper extremity.

Case Description/Methods: A 55-year-old lady, with history of the Antiphospholipid Syndrome, ESRD and chronic DVT of right upper extremity on warfarin presented to the ED with the chief complaint of several episodes of black tarry stools from past 3 days without any associated abdominal pain, hematemesis, hematochezia, any recent use of NSAIDs, any recent weight loss, fever, chills, dysphagia, odynophagia or syncope. In ED, the patient was hypotensive and tachycardic. On examination the patient had dry oral mucosa, right AV fistula, DRE revealed melena, abdominal and skin findings did not reveal any stigmata of chronic liver disease. Initial Labs showed Hb 9.0 gm/dl, Hct 28.5%, INR 5.4, Plt 121, LFTs were normal. The patient was resuscitated with prothrombin complex concentrate and Vitamin K. The patient was given 1 unit of the PRBC and GI was consulted. The patient underwent EGD which revealed Grade II proximal esophageal varices and subsequent variceal band ligation was done. As the varices were in unusual place, hence CT Angiogram of Chest was ordered, which revealed filling defects of the right subclavian vein, right brachiocephalic vein, and SVC with venous collaterals along the right chest wall. Once INR came to therapeutic level, she was started back on warfarin to prevent further thrombosis.

Discussion: Downhill esophageal varices are uncommon entity that result to UGIB, which result from the SVC obstruction. When downhill varix is seen, prompt evaluation of the venous obstruction of veins that drain the esophagus should be made. The upper esophageal plexus drains into the inferior thyroid veins, middle esophageal plexus drains into the azygos, hemiazygos, bronchial, and intercostal veins and all drain into the SVC. The patient might require anticoagulation, thrombectomy or stent placement as per underlying disease. Commonly seen in repeated central venous catheter placement which results to SVC stenosis or thrombus. Other causes can be lung, thymic or thyroid malignancies, mediastinal fibrosis.



Disclosures:


Shreel H. Patel, MD¹, Sushreyta Rose, DO², James Gnecco, DO², Sylvia Keiser, DO², Matthew Schwartz, MD³, Nirav B. Patel, MS⁴, Hareesh Gundlapalli, MD⁵, Jawairia Memon, MD². P2475 - A Rare Case of Upper Gastrointestinal Bleeding: Downhill Esophageal Varices Due to Chronic Deep Vein Thrombosis of Right Upper Extremity, ACG 2024 Annual Scientific Meeting Abstracts. Philadelphia, PA: American College of Gastroenterology.