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Image of the Month
Caput Medusae
CHIA–HSIN LIU and CHIN–HUI HSU
Division of Gastroenterology, Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
A 44-year-old man with chronic hepatitis B virus infection
and alcoholic cirrhosis presented with a 2-month history
of progressive abdominal fullness. On physical examination he
tomography can help distinguish between vena cava obstruc-
tion and portal hypertension.
In the literature, caput medusa–associated complications,
had icteric sclera, shifting dullness, dilated superficial abdomi- such as bleeding of paraumbilical veins, are rare but can be
nal veins (caput medusae) (Figure A), Cruveilhier–Baumgarten life-threatening.4 When it occurs, hemodynamic stabiliza-
murmur, and splenomegaly. Laboratory studies revealed an tion, correction of coagulopathy, and local treatment such as
increased bilirubin level (2.8 mg/dL) and a decreased albumin direct compression or suture ligation of the bleeding varices
level (2.8 mg/dL). Computed tomography revealed a dilated should be performed to control bleeding. Therapeutic inter-
paraumbilical vein (Figure B, arrow), massive ascites, and ventions such as embolization or transjugular intrahepatic
splenomegaly. Oblique sagittal maximum intensity projection portosystemic shunt may be used to decompress the collat-
eral route.4
revealed the dilated paraumbilical vein (Figure C, thin arrow)
and the varicose periumbilical vein (Figure C, thick arrow). He
received large-volume paracentesis, was placed on a sodium- References
1. Missal ME, Robinson JA, Tatum RW, et al. Inferior vena cava
restricted diet, and received diuretics with spironolactone (150
obstruction: clinical manifestations, diagnostic methods, and re-
mg/d) and pulse oral furosemide (40 mg/d). His symptoms lated problems. Ann Intern Med 1965;62:133–161.
improved after 1 week of treatment, and he was followed up at 2. Nieto AF, Doty DB. Superior vena cava obstruction: clinical syn-
our outpatient department. drome, etiology, and treatment. Curr Probl Cancer 1986;10:441–
Patients with cirrhosis-related portal hypertension may pres- 484.
ent with cutaneous manifestations such as visible varicose veins 3. Coetzee T. Clinical anatomy of the umbilicus. S Afr Med J 1980;
on the abdominal wall called caput medusae. 57:463– 466.
4. Lewis CP, Murthy S, Webber SM, et al. Hemorrhage from recana-
Dilated abdominal veins may be caused by clinical condi-
lized umbilical vein in a patient with cirrhosis. Am J Gastroenterol
tions such as inferior vena cava syndrome1 or the superior 1999;94:280.
vena cava syndrome with obstruction of the azygous system.2
To distinguish vena caval obstruction from portal hyperten-
sion, one can pass a finger along the dilated veins located
below the umbilicus to strip them of blood and determine
Conflicts of interest
the direction of blood flow during refilling. However, it is
The authors disclose no conflicts.
difficult to discriminate between the 2 conditions because © 2011 by the AGA Institute
the dilated veins may lack valves and thus have bidirectional 1542-3565/$36.00
blood flow.3 Color Doppler ultrasonography or computed doi:10.1016/j.cgh.2011.03.035
CLINICAL GASTROENTEROLOGY AND HEPATOLOGY 2011;9:xxvi
Downloaded from ClinicalKey.com at Universitas Indonesia December 08, 2016.
For personal use only. No other uses without permission. Copyright ©2016. Elsevier Inc. All rights reserved.
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