Something is not quite right here...

This lady is undergoing a gastroscopy
WHAT IS THE LIKELY DIAGNOSIS?

■ Cirrhosis and portal hypertension

Look again!

■ Splenic vein thrombosis

Gives you gastric varices!

■ Hepatic vein thrombosis

Pts present with ascites and normal LFT's!

■ SVC obstruction

Too easy perhaps?

explanation

‘Downhill oesophageal varices’ are associated with superior vena cava (SVC) obstruction or obstruction or as in this particular endoscopic case, a clot in the right brachiocephalic, subclavian and axillary veins.  I thought that just showing the oesophagus would make the question too difficult and therefore added the photo of a patient with SVC obstruction.  Perhaps this made it too easy ☺! 

Venous drainage of the oesophagus is through the azygos and hemiazygos veins (see below). When there is thrombus, retrograde flow pushes blood towards the heart via collateral channels. If the obstruction is above the level of the azygous vein, varices develop in the upper oesophagus.  However, if the clot is below, or involves the azygous vein, varices will form along the entire oesophagus.

Bleeding is rare as varices in the proximal oesophagus are situated deeper within the submucosa than distal varices.  However, if you are asked to deal with bleeding, you need to place bands at the proximal end of the varix.
Sclerotherapy is contraindicated in the high oesophagus because of the risk of spinal cord infarction and vertebral infarction.  Glue injection should also be avoided as there has been a case report of a massive PE.