A 67-year-old man presented with complaints of gradually progressive difficulty swallowing
for 1 month. The swallowing difficulty was more for solid than for liquid. Over the
last 2 weeks, the patient also complained of chest pain, anorexia, and weight loss.
His general physical examination and basic laboratory investigation were normal. His
esophagogastroduodenoscopy revealed downhill varices with luminal narrowing due to
extrinsic impression extending from 25 to 29 cm from incisor with normal overlying
mucosa ([Fig. 1]). His contrast-enhanced computed tomography of the chest revealed a heterogeneously
enhancing lesion in the superior segment of the right lower lobe with mediastinal
lymphadenopathy with central necrotic area near the carinal bifurcation encasing the
esophagus with significant luminal compromise causing mild upstream dilatation of
esophagus ([Fig. 2]). Ultrasound-guided biopsy from the lung lesion was done and histopathological examination
revealed it to be adenocarcinoma of the lung.
Fig. 1 Esophagogastroduodenoscopy image showing large varices in the proximal and middle
third of the esophagus with no bleeding stigmata (yellow arrow).
Fig. 2 (A) Sagittal section of computed tomography showing mediastinal lymphadenopathy in prevertebral
region (yellow arrow). (B) Cross-sectional computed tomography image showing heterogeneously enhancing lung
lesion in the superior segment of the right lower lobe (orange arrow) with necrotic mediastinal lymphadenopathy at the level of carinal bifurcation (yellow arrow).
Downhill esophageal varices are frequently associated with superior vena cava (SVC)
obstruction and are named based on their cephalad-to-caudal direction of blood flow.
Typically located in the upper third or middle third of the esophagus,[1] these varices arise from causes such as upper mediastinal tumors, most commonly
lung, thyroid, and metastatic tumors. Other contributing factors include mediastinal
fibrosis, surgical ligation of the SVC, and complex Central Venous Catheter (CVC)
placement.[2] As the blood flow in the intrinsic venous structure of the esophagus is intricately
connected to various mediastinal and abdominal tissues through a multitude of veins,
pathologic conditions affecting these areas can also have implications for the venous
plexus of the esophagus.[3]
We present a case of nonbleeding incidental downhill varices on esophagogastroduodenoscopy,
which led to diagnosis of adenocarcinoma of the lung with nodal metastasis.
