--------- ---------- ------------ --------------- ----------------- -------------------- ---------------------- ------------------------- ---------------------------- ----------------------------------------------------------------------------------- This patient was scoped for nagging abdominal pain, but nothing clinically significant was found in the stomach or duodenum. Her past medical history ( Couple of months prior) is significant for a compromise of an indwelling hemodialysis central venous catheter. [Broken External Image]:http://imageshack.us/a/img651/1249/scope.gif Can you clinically correlate the findings on endoscopy ? ans will be posted in a couple of days ( with some neat animations ) (Y)
Hint 1 : This condition has nothing to do with the liver...in other words 'portal hypertension' is not the cause. Hint 2 : It has to do with her past medical history.
Answer: Downhill varices secondary to Sup. Vena Cava Obstruction Discussion - Firstly there is a confusion among many on how to differentiate normal esophageal longitudinal folds from the varices esp as we approach the esophago-gastric junction. So let me clarify that first the normal esophageal folds or rugae are often mistaken for varices. these folds do contain the esophageal veins, but generally don't show through..but whenever there is an obstruction the flow reverses and the back pressure caues them to become tortuous and dilated. These dilated veins are slightly zigzag and throw the overlying mucosa also into zigzag rather than the usual longtitudinal folds. Now revisit the clip above and u can see that in the lower 3rd the folds are perfectly longitudinal and as u move up the esophagus the tortuosity becomes evident. What doe downhill or uphill varices mean w.r.t esophagus ? Ans - it indicates the direction of reversed blood flow in the event of an obstruction. in the normal esophagus blood flow in the upper 2/3 rd of the esophageal plexus in the upward direction and then into the azygous system which drains into the SVC and in the lower 1/3rd thru the coronary or left gastric vein into the portal vein. in the event of an obstruction the direction of flow reverses ( in an attempt to bypass the obstruction ), for ex. in the challenge provided an obstruction in SVC caused a back pressure and subsequent reversal of blood flow in the upper 2/3 rd of esophagus with the blood now flowing in the downward direction..."Downhill Varices". Going by the same toke in the event of Portal hypertension u will hav "uphill varices" I will let the animation do the rest of the talking the black arrow and arrowhead indicate the normal direction of blood flow and the yello arrow indicates the direction of reversed blood flow. i hav uploaded it on youtube...so u can pause and play it at a comfortable speed Causes of SVC syndrome causing downhill varices a) upeer mediastinal neoplasms ( ex. lung cancers, thyroid carcinoma, thymoma, mediastinal lymphoma ) b) vasculitis ex. - Bechet's disease, Systemic venulitis c) miscellaneous - sub sternal goiter, mediastinal fibrosis (Y)
Even though it was inflammation secondary to the indwelling central venous catheter and subsequent obstruction of the SVC which led to the downhill varices..we still won't call it systemic venulitis. That term is usually reserved for inflammation sec. to certain systemic diseases ex. systemic lupus erythematosus.
