Uphill esophageal varices
Double contrast esophagram demonstrates multiple filling defects
that extend proximally from the distal esophagus. There is a rather
serpentine, contiguous appearance to a majority of these lesions.
During the performance of the exam, these filling defects could be
visualized changing in size and other appearance.
Uphill esophageal varices are the result of portal hypertension,
usually the result of hepatic cirrhosis. Other causes include
portal fibrosis, Budd-Chiari and Schistosomiasis. As a result of
this elevated portal venous pressure, multiple collateral pathways
develop in order to bypass the liver. One of these collateral
pathways involves the coronary vein, which in turn anastamoses with
several systemic venous vessels. This vascular engorgement results
in esophageal and proximal gastric varices. Most commonly, these
will present with hemorrhage. The larger the varices, the more
likely they are to result in hemorrhage. Variceal vessels can be
identified by CT, MRI or, as in this case, by double contrast
esophagram. Differential diagnosis for the appearance of esophageal
varices includes varicoid carcinoma as well as reflux esophagitis.
As opposed to varicoid carcinoma, the filling defects of varices
are inconstant, resulting in a changing appearance with peristalsis
and esophageal distention. With reflux esophagitis, there may be a
hiatal hernia present, or other signs of reflux disease. Radiologic
treatment for varices can include a TIPS procedure, whereby a shunt
is created between the portal and systemic veins. If this does not
preclude variceal filling, then at that point, the varices may be
Johnson, C. Daniel. Alimentary Tract Imaging, A Teaching File.
Mosby, Baltimore, 1993 LaBerge, Jeane M.; Gordon, Roy; Kerlan,
Robert; Wilson, Mark. Interventional Radiology Essentials.
Lippincott Williams & Wilkins, Baltimore, 2000