Recognition of downhill esophageal varices in hemodialysis patients requires a high index of clinical suspicion

To the Editor, In the October 2008 edition of Clinical and Experimental Nephrology our group presented a review summarizing eight cases of downhill esophageal varices (DHV) that resulted from superior vena caval (SVC) obstruction in hemodialysis patients [1]. Since then we cared for another patient with this condition. Here we briefly describe our latest case to illustrate the importance of clinical suspicion in achieving the diagnosis and appropriate management of a potentially growing clinical problem in the dialysis population. A 32-year-old African American woman who had been hemodialysis dependent for 6 years for kidney failure from interstitial nephritis presented to a local emergency department with hematemesis. The patient had a functioning arteriovenous graft at presentation, but vascular access history was notable for multiple graft thromboses requiring access revisions as well as use of temporary and tunneled central venous catheters. The patient had been diagnosed with SVC stenosis 2 years previously after developing facial swelling, at which time she was managed by angioplasty with clinical improvement. Two months prior to the hematemesis episode, the patient again developed facial swelling. Recurrent SVC obstruction was confirmed by angiography but initial attempt at recanalization was unsuccessful (Fig. 1a). A plan was made for re-attempt of percutaneous angioplasty. The patient was delayed in returning to angiography due to personal events; in this period she had an episode of ‘‘coffee grounds’’ emesis, prompting the emergency room evaluation. On presentation she was hemodynamically stable; hemoglobin level was 10 g/dl. Given her acute clinical stability, she was discharged from the emergency room with a prescription for famotidine. On recounting the events to her nephrologist later in the day, the nephrologist deemed that timely evaluation for the source of gastrointestinal bleeding was warranted and admitted the patient to the hospital for upper endoscopy. Endoscopy revealed moderate to severe DHV (Fig. 1b); banding was not performed. The next week the patient underwent successful SVC angioplasty with prompt relief of facial edema. She has been free of signs of both gastrointestinal hemorrhage and facial plethora over 9 months of follow-up. Since its initial description by Pop and Cutler in 1998 [2], fewer than ten cases of DHV among dialysis patients have been reported in the literature. Concurrent with of our review of eight cases, Caderwood and Mishkin reported DHV in another hemodialysis patient in 2008; in that instance the patient presented with hemodynamically unstable gastrointestinal hemorrhage [3]. Like the case of Caderwood and our most recent patient, all published cases of DHV in dialysis patients share a consistent sequence of presentation and ensuing evaluation in which gastrointestinal hemorrhage prompts endoscopy. Thus in contrast to uphill varices related to portal hypertension, to date there are no reports of DHV identified in dialysis patients prior to gastrointestinal hemorrhage. While varices were not found U. Muthyala Department of Internal Medicine, Barnes Jewish Hospital, St. Louis, MO, USA