A 55-year-old man with cirrhosis presents with hematemesis. On endoscopy, esophageal varices are identified. The varices develop due to portal hypertension, which causes dilation of portosystemic anastomoses. At which of the following anatomical sites is the esophageal venous plexus directly continuous with the portal venous system?

Explanation

## Esophageal Varices and Portosystemic Anastomoses **Key Point:** The esophageal venous plexus is directly continuous with the **left gastric vein** (also called the coronary vein of the stomach), which drains directly into the **portal vein**. This is the primary site of portosystemic anastomosis in esophageal varices. **Anatomical Pathway:** - **Esophageal venous plexus** → **Left gastric vein** → **Portal vein** - The left gastric vein ascends along the lesser curvature of the stomach and esophagus - It enters the portal vein at the junction of the splenic and superior mesenteric veins **Portosystemic Anastomoses in Portal Hypertension:** | Site | Systemic Vein | Portal Vein Tributary | Clinical Manifestation | |---|---|---|---| | **Esophagus** | Azygos system | Left gastric vein | Esophageal varices | | **Rectum** | Middle/inferior rectal | Superior rectal vein | Rectal varices | | **Umbilicus** | Superficial epigastric | Left/right portal vein | Caput medusae | | **Retroperitoneum** | Lumbar veins | Colic veins | Retroperitoneal varices | **Clinical Pearl:** Esophageal varices are the most dangerous portosystemic anastomoses because they are prone to rupture, causing life-threatening hemorrhage. The left gastric vein is the critical link between the esophageal plexus and the portal system. **High-Yield:** In portal hypertension, blood backs up through the left gastric vein into the esophageal plexus, causing varices. This is why variceal bleeding is a common complication of cirrhosis.