背景:近端或下坡食管静脉曲张是上消化道出血的罕见原因。与更常见的远端食管静脉曲张不同,最常见的是门静脉高压的结果,下坡食管静脉曲张是由上腔静脉(SVC)的血管阻塞引起的。虽然SVC梗阻最常见的是继发于恶性原因,我们对文献的回顾表明,SVC梗阻的良性原因是下坡静脉曲张引起的实际出血的最常见原因.鉴于下坡静脉曲张的替代病理生理学,他们需要一种独特的管理方法。静脉曲张带结扎可用于治疗急性静脉曲张破裂出血,并且应该应用于varx的近端。缓解潜在的SVC阻塞是确定治疗下坡静脉曲张的基石。
方法:一名年轻女性患者,由于颈内静脉透析导管的隧道,出现良性上腔静脉狭窄,并伴有呕血和黑便。紧急上消化道内镜检查显示多个“下坡”食管静脉曲张伴近期出血的柱头。因为没有活动性出血,未进行内镜干预.CT血管造影显示她留置的血液透析导管远端周围的SVC狭窄。患者接受了狭窄SVC段的球囊血管成形术,出血和临床稳定。
结论:下坡食管静脉曲张与更常见的远端食管静脉曲张不同。内镜治疗在延缓活动性静脉曲张出血方面有作用,但缓解潜在的SVC梗阻是治疗的基石,应尽快进行.不知道为什么是良性的,而不是恶性的,SVC阻塞的原因导致下坡静脉曲张以如此高的速度出血,尽管是SVC梗阻的少见病因。
BACKGROUND: Proximal or \'downhill\' esophageal varices are a rare cause of upper gastrointestinal hemorrhage. Unlike the much more common distal esophageal varices, which are most commonly a result of portal hypertension, downhill esophageal varices result from vascular obstruction of the superior vena cava (SVC). While SVC obstruction is most commonly secondary to malignant causes, our
review of the literature suggests that benign causes of SVC obstruction are the most common cause actual bleeding from downhill varices. Given the alternative pathophysiology of downhill varices, they require a unique approach to management. Variceal band ligation may be used to temporize acute variceal bleeding, and should be applied on the proximal end of the varix. Relief of the underlying SVC obstruction is the cornerstone of definitive treatment of downhill varices.
METHODS: A young woman with a benign superior vena cava stenosis due to a tunneled internal jugular vein dialysis catheter presented with hematemesis and melena. Urgent upper endoscopy revealed multiple \'downhill\' esophageal varices with stigmata of recent hemorrhage. As there was no active bleeding, no endoscopic intervention was performed. CT angiography demonstrated stenosis of the SVC surrounding the distal tip of her indwelling hemodialysis catheter. The patient underwent balloon angioplasty of the stenotic SVC segment with resolution of her bleeding and clinical stabilization.
CONCLUSIONS: Downhill esophageal varices are a distinct entity from the more common distal esophageal varices. Endoscopic therapies have a role in temporizing active variceal bleeding, but relief of the underlying SVC obstruction is the cornerstone of treatment and should be pursued as rapidly as possible. It is unknown why benign, as opposed to malignant, causes of SVC obstruction result in bleeding from downhill varices at such a high rate, despite being a less common etiology of SVC obstruction.