Unusual Life-Threatening Complication of a Substernal Goiter: A Case of an Upper Gastrointestinal Bleed

Substernal goiter represents a common and challenging clinical scenario in medical practice. Symptoms often include dysphagia, dyspnea, and hoarseness, deeming the vascular compressive symptoms an unusual finding. In extraordinarily rare cases, its slow and gradual growth determines the emergence of severe superior vena cava syndrome, with consequent development of upper esophageal downhill varices. In contrast with distal esophageal varices, downhill variceal hemorrhage is extremely rare. The authors report a patient admitted to the emergency room due to upper gastrointestinal hemorrhage, caused by downhill upper esophageal varices' rupture, secondary to compressive substernal goiter. In this case, irregular follow-up resulted in massive thyroid growth, progressive vascular and airway compression, and the development of venous collateral pathways. Despite the severity of those compressive symptoms, the patient was not a surgical candidate considering her multiple cardiovascular and respiratory comorbidities. Newly developed thyroid ablative techniques may emerge as a possible life-saving treatment when the surgical approach cannot be considered.