Pulmonary Hypertension and Downhill Varices: An Incidental Finding

Downhill varices (DV), rare proximal esophageal varices, are typically associated with superior vena cava (SVC) obstruction. We present the case of an 80-year-old male with severe pulmonary hypertension and chronic obstructive pulmonary disease who presented with shortness of breath upon exertion along with new melena and anemia (hemoglobin 5.9 g/dL). Upper endoscopy revealed non-bleeding DV in the proximal esophagus and a vascular lesion on the tongue, with imaging and venography excluding SVC obstruction. Severe pulmonary hypertension was identified via transthoracic echocardiogram (TTE) and right heart catheterization (RHC) as the probable cause of DV via venous backflow and increased central venous pressure. The patient's anemia improved with supportive care, and no further gastrointestinal bleeding occurred. Management involves identifying and addressing the underlying cause, with endoscopic intervention reserved for active bleeding. This case highlights the importance of recognizing DV as a potential complication of pulmonary hypertension and underscores the need for individualized diagnostic and therapeutic approaches.