Bleeding Downhill Esophageal Varices Secondary to Superior Vena Cava Stenosis From a Long-Term Indwelling Chemotherapy Port: A Case Report.

Downhill esophageal varices are a rare cause of upper gastrointestinal bleeding and differ from distal esophageal varices associated with portal hypertension. They usually occur when obstruction of the superior vena cava (SVC) redirects venous flow through collateral pathways involving the esophageal venous plexus. We report the case of a 71-year-old man with a history of colon cancer in remission, status post partial colectomy with ostomy, who presented with recurrent hematemesis and dark stools. Upper gastrointestinal endoscopy showed large proximal esophageal varices consistent with downhill varices, and endoscopic band ligation was performed for bleeding control. Further evaluation with contrast-enhanced computed tomography of the chest demonstrated severe focal SVC stenosis in the setting of a long-standing indwelling chemotherapy port catheter, with catheter-associated thrombus and prominent collateral vessels. Interventional radiology removed the chemotherapy port catheter and performed balloon angioplasty/serial balloon dilation of the SVC stenosis up to 12 mm without stent placement during the index intervention, with improved venographic flow. This case highlights the importance of considering SVC obstruction when proximal esophageal varices are identified, especially in patients with a history of long-term central venous catheters or chemotherapy ports. Although endoscopic therapy can control acute bleeding, definitive management should address the underlying venous obstruction to reduce the risk of recurrence.