Upper gastrointestinal hemorrhage from downhill esophageal varices

Two cases of proximal esophageal varices due to a primary and a recurrent goiter are reported. One of the patients presented with massive upper gastrointestinal hemorrhage 44 years after subtotal resection of a thyroid gland. "Downhill" esophageal varices may serve as collaterals either to bypass superior vena caval obstruction via azygous vein or to drain the superior systemic system to the portal vein when both the superior vena cava and the azygous vein are occluded. They may also arise, as in our bleeding patient, from previous thyroid surgery without any symptoms of superior vena caval congestion. Therefore, downhill varices should be suspected as the origin of upper gastrointestinal hemorrhage not only in patients with obvious superior vena caval obstruction, buy also in any case of thyroid disease or a history of thyroid surgery. If conservative measures are insufficient, emergency management may include balloon tamponade or endoscopic sclerotherapy.