E40 UCTN – Unusual cases and technical notes

Downhill varices resulting from giant intrathoracic goiter

Fig. 2 Sagittal com- puted tomography of the chest. The goiter was immense, reaching the aortic arch, sur- rounding the trachea and partially compres- sing the upper esopha- gus. The esophagus was additionally com- pressed by anterior spinal spondylophytes.

Fig. 1 Multiple submucosal veins in the upper esophagus, consistent with downhill varices.

An 82-year-old man was admitted to the hospital because of substernal chest pain, dyspnea, and occasional dysphagia to sol- ids. His past medical history was remark- geal varices are called “downhill varices”, References able for diabetes mellitus type II, hyper- as they are located in the upper esophagus 1 Kotfila R, Trudeau W. Extraesophageal vari- – lipidemia, and Parkinson’s disease. On and project downwards. Downhill varices ces. Dig Dis 1998; 16: 232 241 2 Basaranoglu M, Ozdemir S, Celik AF et al. A occur as a result of shunting in cases of up- physical examination he appeared frail case of fibrosing mediastinitis with obstruc- but with no apparent distress. Examina- per systemic venous obstruction from tion of superior vena cava and downhill tion of the neck showed no masses, stri- space-occupying lesions in the medias- esophageal varices: a rare cause of upper dor or jugular venous distension. Heart tinum [2,3]. Downhill varices as a result of gastrointestinal hemorrhage. J Clin Gastro- – examination disclosed a regular rate and mediastinal processes are reported to enterol 1999; 28: 268 270 3 Calderwood AH, Mishkin DS. Downhill rhythm; however a 2/6 systolic ejection occur in up to 50% of patients [3,4]. In our esophageal varices caused by catheter-relat- murmur was apparent. The lung and ab- patient, the presence of downhill varices ed thrombosis. Clin Gastroenterol Hepatol dominal examinations were unremark- led to the discovery of a giant intrathoracic 2008; 6: e1 able, and laboratory data were within re- goiter. Blood from the thyroid plexus flows 4 van der Veldt AA, Hadithi M, Paul MA et al. An unusual cause of hematemesis: Goiter. ference ranges. Myocardial ischemia was through the inferior thyroid veins into the World J Gastroenterol 2006; 12: 5412–5415 ruled out. Because of the intermittent brachiocephalic vein [4]. In cases of ob- 5 Tsokos M, Bartel A, Schoel R et al. Fatal pul- dysphagia an esophagogastroduodenos- struction of the thyroid veins, blood flows monary embolism after endoscopic emboli- copy (EGD) was performed, which re- via the deep esophageal veins, resulting in zation of downhill esophageal varix. Dtsch – vealed multiple submucosal veins in the proximal varices. Although these varices Med Wochenschr 1998; 123: 691 695 upper esophagus, consistent with down- usually do not bleed, occasionally they can hill varices (●" Fig. 1). Computed tomog- result in catastrophic hemorrhage. In cases Bibliography DOI 10.1055/s-0029-1215290 raphy (CT) of the chest found a large ret- of bleeding, endoscopic band ligation or Endoscopy 2010; 42: E40 angiographic therapy is recommended as rosternal goiter extending into the me- © Georg Thieme Verlag KG Stuttgart · New York · ●" diastinum ( Fig. 2). This was not treated injection of sclerosants can result in sys- ISSN 0013-726X as there was no evidence of bleeding or temic embolization through the brachio- This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited. bleeding stigmata. The patient was of- cephalic vein [5]. Corresponding author fered surgical resection of the large goiter. L. J. Ulbricht, MD, PhD However, due to his advanced age he pre- Endoscopy_UCTN_Code_CCL_1AB_2AC_3AG University of Witten-Herdecke ferred to be treated conservatively. Departments of Internal Medicine and Cardiology The most commonly encountered varices K. Mönkemüller1, D. Poppen1, K. Feld- Marienhospital Bottrop Josef-Albers-Str. 70 of the esophagus are those secondary to mann2, L. J. Ulbricht3,4 46236 Bottrop 1 portal hypertension, which are found in Department of Internal Medicine and Germany the distal esophagus or fundus of the Gastroenterology, Marienhospital Fax: +49-20-411061009 stomach. Portal hypertension can lead to Bottrop, Bottrop, Germany [email protected] ectopic varices, which can be found any- 2 Department of Radiology, Marien- where in the gastrointestinal tract, includ- hospital Bottrop, Bottrop, Germany ing the small bowel and colorectum [1]. 3 Department of Cardiology, Marien- However, ectopic varices related to portal hospital Bottrop, Bottrop, Germany hypertension are almost never found in 4 University of Witten/Herdecke, Witten, the proximal esophagus. Proximal esopha- Germany

Mönkemüller K et al. Downhill varices as a result from a giant intrathoracic goiter… Endoscopy 2010; 42: E40