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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
had icteric sclera, shifting dullness, dilated superficial abdomi-
nal veins (caput medusae) (Figure A), Cruveilhier–Baumgarten
murmur, and splenomegaly. Laboratory studies revealed an
increased bilirubin level (2.8 mg/dL) and a decreased albumin
level (2.8 mg/dL). Computed tomography revealed a dilated
paraumbilical vein (Figure B, arrow), massive ascites, and
splenomegaly. Oblique sagittal maximum intensity projection
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-
restricted diet, and received diuretics with spironolactone (150
mg/d) and pulse oral furosemide (40 mg/d). His symptoms
improved after 1 week of treatment, and he was followed up at
our outpatient department.
Patients with cirrhosis-related portal hypertension may pres-
ent with cutaneous manifestations such as visible varicose veins
on the abdominal wall called caput medusae.
Dilated abdominal veins may be caused by clinical condi-
tions such as inferior vena cava syndrome1 or the superior
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
the direction of blood flow during refilling. However, it is
difficult to discriminate between the 2 conditions because
the dilated veins may lack valves and thus have bidirectional
blood flow.3 Color Doppler ultrasonography or computed
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tomography can help distinguish between vena cava obstruc-
tion and portal hypertension.
In the literature, caput medusa–associated complications,
such as bleeding of paraumbilical veins, are rare but can be
life-threatening.4 When it occurs, hemodynamic stabiliza-
tion, correction of coagulopathy, and local treatment such as
direct compression or suture ligation of the bleeding varices
should be performed to control bleeding. Therapeutic inter-
ventions such as embolization or transjugular intrahepatic
portosystemic shunt may be used to decompress the collat-
eral route.4
References
1. Missal ME, Robinson JA, Tatum RW, et al. Inferior vena cava
obstruction: clinical manifestations, diagnostic methods, and re-
lated problems. Ann Intern Med 1965;62:133–161.
2. Nieto AF, Doty DB. Superior vena cava obstruction: clinical syn-
drome, etiology, and treatment. Curr Probl Cancer 1986;10:441–
484.
3. Coetzee T. Clinical anatomy of the umbilicus. S Afr Med J 1980;
57:463– 466.
4. Lewis CP, Murthy S, Webber SM, et al. Hemorrhage from recana-
lized umbilical vein in a patient with cirrhosis. Am J Gastroenterol
1999;94:280.
Conflicts of interest
The authors disclose no conflicts.
© 2011 by the AGA Institute
1542-3565/$36.00
doi:10.1016/j.cgh.2011.03.035
CLINICAL GASTROENTEROLOGY AND HEPATOLOGY 2011;9:xxvi