Imaging description

Mid and upper esophageal (downhill) varices cause nonspecific thickening of the esophageal wall by CT chest without intravenous contrast material. These varices enhance after intravenous contrast material administration. Periesophageal varices are often present as well. Downhill varices are diagnosed by their location and by the associated signs of superior vena cava (SVC) obstruction (Figure 39.1). They are often smaller than distal esophageal uphill varices.

Importance

Downhill esophageal varices result from SVC obstruction; they are much less common than uphill varices secondary to cirrhosis and portal venous hypertension. Obstruction of the SVC often results from thrombosis and a common cause of SVC thrombosis is chronic catheterization. Other causes of SVC obstruction are mediastinal metastases, lymphoma, substernal goiter, mediastinal radiation, and sclerosing mediastinitis [1]. Blood bypasses the obstructed SVC by flowing inferiorly through esophageal and periesophageal veins into the inferior vena cava or into the portal circulation. Downhill varices are only one of many collateral pathways that blood can follow to return to the heart when the SVC is occluded; azygos, hemiazygos, and chest wall veins provide other collateral pathways. Therefore, the volume of blood flowing through downhill varices is typically less than the volume of blood flowing through uphill varices. Consequently, downhill varices tend to be smaller than uphill varices and are less likely to bleed than uphill varices.