CTICasesMassive Paraesophageal Varices
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Imaging findings
A chest radiograph shows an extra opacity behind the heart without a clear air-fluid level. The lateral view confirms a right-sided effusion (and a tiny left-sided effusion) and no air-fluid level. CT reveals massive ascites and demonstrates that the opacity behind the heart consists of huge paraesophageal varices. These varices anastomose extensively and drain into the azygos and hemiazygos vein system. The patient's liver appears shrunken, and the left inferior pulmonary vein does not appear unusually big.
Key takeaways
Not every opacity behind the heart represents a hiatal hernia; other explanations, such as massive paraesophageal varices, must be considered, especially in patients with portal hypertension and ascites, and in the absence of an air-fluid level. These varices can be incredibly large and form extensive networks connecting to the azygos system. Differentiation from pulmonary vein shunts requires careful assessment.
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