A very rare cause of upper GIB: Dr. Mohamed Shekhani
Background: <ul><li>Common causes of UGIB include peptic ulcer disease & esophageal varices.  </li></ul><ul><li>Sometimes ...
Aims: <ul><li>To raise the awareness of the presence of such a rare cause of UGIB in case another endoscopist faces such e...
Setting: <ul><li>The emergency GIB unit of Kudistan center for gastroenterology & hepatology – Sulaimania-Iraqi  Kurdistan...
Case history & findings: <ul><li>55 YEARS OLD FEMALE presented with fresh bleeding from the mouth. </li></ul><ul><li>Emerg...
 
CT scan: of the neck and chest with i.v contrast
 
Case history & findings: <ul><li>Upper GIT endoscopy revealed esophageal varices in the upper 1/3 extending to the pharynx...
60 YS old female with long-standing inoperable carotid body tumor presented with upper GIB:DOWNHILL upper eso/pharyngeal  ...
60 YS old female with long-standing inoperable carotid body tumor presented with upper GIB:DOWNHILL upper eso/pharyngeal  ...
60 YS old female with long-standing inoperable carotid body tumor presented with upper GIB:DOWNHILL upper eso/pharyngeal  ...
60 YS old female with long-standing inoperable carotid body tumor presented with upper GIB:DOWNHILL upper eso/pharyngeal  ...
60 YS old female with long-standing inoperable carotid body tumor presented with upper GIB:DOWNHILL upper eso/pharyngeal  ...
60 YS old female with long-standing inoperable carotid body tumor presented with upper GIB:DOWNHILL upper eso/pharyngeal  ...
60 YS old female with long-standing inoperable carotid body tumor presented with upper GIB:DOWNHILL upper eso/pharyngeal  ...
60 YS old female with long-standing inoperable carotid body tumor presented with upper GIB:DOWNHILL upper eso/pharyngeal  ...
60 YS old female with upper eso/pharyngeal  varices: A varix with site of recent bleeding.
60 YS old female with long-standing inoperable carotid body tumor presented with upper GIB:DOWNHILL upper eso/pharyngeal  ...
60 YS old female with long-standing inoperable carotid body tumor presented with upper GIB:DOWNHILL upper eso/pharyngeal  ...
60 YS old female with long-standing inoperable carotid body tumor presented with upper GIB:DOWNHILL upper eso/pharyngeal  ...
60 YS old female with long-standing inoperable carotid body tumor presented with upper GIB:DOWNHILL upper eso/pharyngeal  ...
Conclusion & discussion: <ul><li>DHEV is a term used to contrast it with the more common form of esophageal varices namely...
Conclusion & discussion: <ul><li>Downhill varices should be considered in any patient with superior vena caval obstruction...
References: <ul><li>1.Fleig WE ,  Stange EF ,  Ditschuneit H . Upper gastrointestinal hemorrhage from downhill esophageal ...
References: <ul><li>5.Anderson IF, Dannheimer I.A case of &quot;downhill varices&quot;.;S Afr Med J. 1970 Sep 12;44(36):10...
References: <ul><li>Johnson LS, Kinnear DG, Brown RA, Mulder DS.'Downhill' esophageal varices. A rare cause of upper gastr...
References: <ul><li>Hussein FA, Mawla N, Befeler AS, Martin KJ, Lentine KL.Formation of downhill esophageal varices as a r...
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Git a very rare cause of upper gib.

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A VERY RARE CAUSE OF Upper GIT Bleeding.

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Git a very rare cause of upper gib.

  1. 1. A very rare cause of upper GIB: Dr. Mohamed Shekhani
  2. 2. Background: <ul><li>Common causes of UGIB include peptic ulcer disease & esophageal varices. </li></ul><ul><li>Sometimes rare causes are discovered during upper GIT endoscopy which are not diagnosed without good experience & theoretical background. </li></ul>
  3. 3. Aims: <ul><li>To raise the awareness of the presence of such a rare cause of UGIB in case another endoscopist faces such endoscopic finding in a similar clinical context. </li></ul>
  4. 4. Setting: <ul><li>The emergency GIB unit of Kudistan center for gastroenterology & hepatology – Sulaimania-Iraqi Kurdistan. </li></ul>
  5. 5. Case history & findings: <ul><li>55 YEARS OLD FEMALE presented with fresh bleeding from the mouth. </li></ul><ul><li>Emergency endoscopy was requested on admission to Emergency Room. </li></ul><ul><li>On clinical examination a large left-sided neck mass with dilated veins on its surface was found. </li></ul><ul><li>This mass was present for years, not operated upon because it was said to be inoperable & was diagnosed as carotid body tumor. </li></ul>
  6. 7. CT scan: of the neck and chest with i.v contrast
  7. 9. Case history & findings: <ul><li>Upper GIT endoscopy revealed esophageal varices in the upper 1/3 extending to the pharynx, with no active bleeding but one varices had red signs indicating recent bleeding, there was a cloted blood in the antrum &duodenum. </li></ul><ul><li>No endoscopic band ligation (EBL) was done because there was no active bleeding. </li></ul><ul><li>She had another attack of bleeding after 2 days & was sent again for emergency OGD & the findings were the same & no interventions done. </li></ul><ul><li>Cardiothoracic surgery consultation confirmed the diagnosis of carotid body tumor & surgically removed. </li></ul>
  8. 10. 60 YS old female with long-standing inoperable carotid body tumor presented with upper GIB:DOWNHILL upper eso/pharyngeal varices
  9. 11. 60 YS old female with long-standing inoperable carotid body tumor presented with upper GIB:DOWNHILL upper eso/pharyngeal varices
  10. 12. 60 YS old female with long-standing inoperable carotid body tumor presented with upper GIB:DOWNHILL upper eso/pharyngeal varices
  11. 13. 60 YS old female with long-standing inoperable carotid body tumor presented with upper GIB:DOWNHILL upper eso/pharyngeal varices
  12. 14. 60 YS old female with long-standing inoperable carotid body tumor presented with upper GIB:DOWNHILL upper eso/pharyngeal varices
  13. 15. 60 YS old female with long-standing inoperable carotid body tumor presented with upper GIB:DOWNHILL upper eso/pharyngeal varices
  14. 16. 60 YS old female with long-standing inoperable carotid body tumor presented with upper GIB:DOWNHILL upper eso/pharyngeal varices
  15. 17. 60 YS old female with long-standing inoperable carotid body tumor presented with upper GIB:DOWNHILL upper eso/pharyngeal varices
  16. 18. 60 YS old female with upper eso/pharyngeal varices: A varix with site of recent bleeding.
  17. 19. 60 YS old female with long-standing inoperable carotid body tumor presented with upper GIB:DOWNHILL upper eso/pharyngeal varices
  18. 20. 60 YS old female with long-standing inoperable carotid body tumor presented with upper GIB:DOWNHILL upper eso/pharyngeal varices
  19. 21. 60 YS old female with long-standing inoperable carotid body tumor presented with upper GIB:DOWNHILL upper eso/pharyngeal varices approaching the larynx
  20. 22. 60 YS old female with long-standing inoperable carotid body tumor presented with upper GIB:DOWNHILL upper eso/pharyngeal varices reaching the larynx.
  21. 23. Conclusion & discussion: <ul><li>DHEV is a term used to contrast it with the more common form of esophageal varices namely the uphill esophageal varices which occur in chronic liver disease or splenic vein thrombosis. </li></ul><ul><li>DHEV occurs in cases of Superior vena caval (SVC) obstruction of various causes as SVC thromnosis or obstruction. </li></ul><ul><li>The pathophysiological basis of DHEV formation is that it serves as collaterals either to bypass SVC 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 (1,2). </li></ul><ul><li>The first cases of DHEV were published during sixties & seventies in which the causes were SVC obstruction( secondary to malignant lymphoma,malignant thymoma,malignant thyroid tumor,retrosternal goiter,Behcet syndrome&bronchogenic carcinoma) at the level of azygous vein which drains the upper esophagus(3-11). </li></ul>
  22. 24. Conclusion & discussion: <ul><li>Downhill varices should be considered in any patient with superior vena caval obstruction from any cause. (9). </li></ul><ul><li>With the frequent introduction of central venous access for hemodialysis, cancer chemotherapy& nutritional support, DHEV is now more frequently caused by catheter-related SVC thrombosis(12-17) . </li></ul><ul><li>Carotid body tumor not mentioned before as a cause of DHEV. </li></ul><ul><li>UGIB is not a common presentation of DHEV, but can occur (1). </li></ul><ul><li>Treatment is of the underlying cause but EBL,sclerotherapy or surgery, can control bleeding in cases in which the underlying cause cannot be removed(18). </li></ul>
  23. 25. References: <ul><li>1.Fleig WE , Stange EF , Ditschuneit H . Upper gastrointestinal hemorrhage from downhill esophageal varices. Dig Dis Sci. 1982 Jan;27(1):23-7. </li></ul><ul><li>2.David J. Case, B.A., Ronica Case, Rajasekhara Mummadi,, Gottumukkala S. Raju., http://daveproject.org/downhill+esophageal+varices </li></ul><ul><li>3.FELSON B, LESSURE AP.DOWNHILL&quot; VARICES OF THE ESOPHAGUS.; Dis Chest; 1964 Dec;46:740-6. </li></ul><ul><li>4.Subramaniam R, Madanagopalan N, Krishnan KT, Padmanabhan C.A case of anaplastic bronchogenic carcinoma with &quot;downhill varices&quot; of the esophagus.; Dis Chest. 1967 May;51(5):545-9. </li></ul><ul><li>5.Sheiner NM, Palayew MJ.Downhill&quot; esophageal varices in superior vena caval obstruction.;Can Med Assoc J. 1969 May 24;100(20):961-5. </li></ul>
  24. 26. References: <ul><li>5.Anderson IF, Dannheimer I.A case of &quot;downhill varices&quot;.;S Afr Med J. 1970 Sep 12;44(36):1035-7. </li></ul><ul><li>Gerstenberg E, Taenzer V, Bachmann D, Wöllgens P.Downhill varices: esophageal varices without portal hypertension].;Med Welt. 1971 Sep 11;22(37):1433-6. </li></ul><ul><li>Pugliese FM.A surgical approach to bleeding downhill varices.;Angiology. 1973 Nov;24(10):606-11. </li></ul><ul><li>Sorokin JJ, Levine SM, Moss EG, Biddle CM.Downhill varices: report of a case 29 years after resection of a substernal thyroid gland.;Gastroenterology. 1977 Aug;73(2):345-8. </li></ul><ul><li>van Beusekom HJ, Beex LV, Smals AG, Snel P, Kloppenborg PW.Downhill esophageal varices in thyroid carcinoma].;Ned Tijdschr Geneeskd. 1978 Jan 14;122(2):38-41 </li></ul>
  25. 27. References: <ul><li>Johnson LS, Kinnear DG, Brown RA, Mulder DS.'Downhill' esophageal varices. A rare cause of upper gastrointestinal bleeding.;Arch Surg. 1978 Dec;113(12):1463-4 </li></ul><ul><li>Blam ME, Kobrin S, Siegelman ES, Scotiniotis IA.&quot;Downhill&quot; esophageal varices as an iatrogenic complication of upper extremity hemodialysis access.;Am J Gastroenterol. 2002 Jan;97(1):216-8. </li></ul><ul><li>Greenwell MW, Basye SL, Dhawan SS, Parks FD, Acchiardo SR.Dialysis catheter-induced superior vena cava syndrome and downhill esophageal varices.;Clin Nephrol. 2007 May;67(5):325-30. </li></ul><ul><li>Calderwood AH, Mishkin DS.Downhill esophageal varices caused by catheter-related thrombosis.;Clin Gastroenterol Hepatol. 2008 Jan;6(1):e1. </li></ul>
  26. 28. References: <ul><li>Hussein FA, Mawla N, Befeler AS, Martin KJ, Lentine KL.Formation of downhill esophageal varices as a rare but serious complication of hemodialysis access: a case report and comprehensive literature review;Clin Exp Nephrol. 2008 Oct;12(5):407-15. Epub 2008 Apr 10. </li></ul><ul><li>Gopaluni S, Warwicker P.Superior vena cava obstruction presenting with epistaxis, haemoptysis and gastro-intestinal haemorrhage in two men receiving haemodialysis with central venous catheters: two case reports;J Med Case Reports. 2009 May 27;3:6180. </li></ul><ul><li>Basar N, Cagli K, Basar O, Sen N, Gurel OM, Akpinar I,etall. Upper-extremity deep vein thrombosis and downhill esophageal varices caused by long-term pacemaker implantation;Tex Heart Inst J. 2010;37(6):714-6. </li></ul><ul><li>Froilán C, Adán L, Suárez JM, Gómez S, Hernández L, Plaza R,etall. Therapeutic approach to &quot;downhill&quot; varices bleeding;Gastrointest Endosc. 2008 Nov;68(5):1010-2. Epub 2008 Apr 24. </li></ul>
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