Ann Thorac Surg 2007;83:359-360
© 2007 The Society of Thoracic Surgeons
Correspondence
"Downhill" Varices—Banding Proximal To Varix?
Saurabh S. Dhawan, MD
Department of Internal Medicine, University of Tennessee Health Science Center, Memphis, TN 38103
(Email: csaurabh{at}gmail.com).
To the Editor:
I read with great interest the article by Bedard and Deslauriers [1], which described massive upper gastrointestinal (GI) bleeding in a patient from "downhill" varices secondary to a large posterior mediastinal goiter, and resolution with resection of the large mass. Also mentioned was that in acute situations, variceal banding could be used as a temporizing measure. Review of the literature using MEDLINE and MeSH terms "downhill varices" reveals multiple reports of "downhill" varices treated with a combination of banding, superior vena caval stents, and grafting. However, there seems to be paucity in the literature describing site of banding in "downhill" varices.
Felson and Lessure [2] first described "downhill" varices and their hemodynamics in 1964, and named them such because of their direction of flow, and stated their typically proximal location in the esophagus. In contrast, "uphill" varices are seen in portal hypertension, are distal, and by far are the most common type. Variceal banding in "uphill" varices is typically done distally to decrease blood flow from the feeding vessels below. In contrast, I speculate that variceal banding for "downhill" varices should be done proximally. Gastroenterologists may, by default, band the varix distally and thereby increase intravariceal pressure that could result in a potentially worse GI bleed. In most cases, this issue probably has not been raised because of concomitant superior vena caval stent placement or resection of the impinging mass (as seen in the case described), which decompresses the entire system mitigating the potentially harmful effect of distal banding.
In conclusion, knowledge of the hemodynamics of "downhill" varices and placement of bands proximal to the varix may be worth speculating about for gastroenterologists worldwide, given that banding is considered safer than sclerotherapy for proximal varices, the latter known to have caused spinal cord infarction [3] and pulmonary embolism [4]. Given the rarity of "downhill" varices, there is lack of objective data to support this technique, but it can be speculated that proximal banding would yield better temporizing results. This may be more important, especially if stent placement were to be delayed for reasons such as unavailability of interventional radiologists or bacteremia complicating the hospital stay, in which case a potentially lethal GI bleed could occur.
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References
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- Bedard EL, Deslauriers J. Bleeding "downhill" varices: a rare complication of intrathoracic goiter Ann Thorac Surg 2006;81:358-360.[Abstract/Free Full Text]
- Felson B, Lessure AP. "Downhill" varices of the esophagus Dis Chest 1964;46:740-744.[Medline]
- Seidman E, Weber AM, Morin CL, et al. Spinal cord paralysis following sclerotherapy for esophageal varices Hepatology 1984;4:950-954.[Medline]
- Tsokos M, Bartel A, Schoel R, Rabenhorst G, Schwerk WB. Fatal pulmonary embolism after endoscopic embolization of downhill esophageal varix Dtsch Med Wochenschr [German] 1998;123:691-695.
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