Downhill Esophageal Variceal Hemorrhage Secondary to Superior Vena Cava Obstruction in a Patient With End-Stage Renal Disease: A Rare and Under-Recognized Complication.

Downhill esophageal varices, an uncommon etiology of upper gastrointestinal bleeding, arise from superior vena cava obstruction rather than portal hypertension. Etiologies include malignancy, intravascular devices, and dialysis-related central venous stenosis. A 79-year-old man with end-stage renal disease on hemodialysis presented with melena and hematemesis. Endoscopy revealed large proximal esophageal varices; imaging showed chronic superior vena cava stenosis related to his indwelling dialysis catheter. Endoscopic band ligation followed by balloon venoplasty achieved hemostasis and endovascular patency. This case illustrates downhill variceal bleeding as a sequela of hemodialysis catheter associated superior vena cava stenosis and emphasizes the significance of timely identification and management.