Case description: 

A 87-year-old patient presented to our emergency department with hematemesis and melena. With an initial hemoglobin level of 5 g/dL, two units of packed red blood cells were transfused before the hemodynamically stable patient was transferred to our endoscopy unit.

Emergency upper endoscopy revealed a column of downhill varices with stigmata of recent bleeding, characterized by a white nipple sign. During inspection, active bleeding from the downhill varix recurred. The remaining esophagus and stomach showed no signs of portal hypertensive gastropathy or additional varices.

Due to acitve hemorrhage, endoscopic band ligation was performed using a multiband ligator, resulting in immediate hemostasis. No additional endoscopic therapy was required.

To clarify the etiology of the downhill varices, contrast-enhanced CT of the chest was obtained. It demonstrated a 3.7 × 9 mm thrombus in the superior vena cava with collateralization through the azygos system. The patient had a previously implanted a CRT-D device for complete atrioventricular block, and the transvenous leads were regarded as the causative factor for the SVC thrombosis.

The patient was started on anticoagulation. Given the elevated risk of damaging the CRT-D system, an initial attempt was made to embolize the azygos vein. However, the procedure proved technically unfeasible, and the patient is now being evaluated for stenting of the superior vena cava.

Conclusion:

Acute bleeding from downhill esophageal varices is rare but can be effectively treated with endoscopic band ligation. Identification and management of the underlying SVC obstruction is crucial for preventing recurrence.