Subsequent hepatic repair mechanisms The term caput medusae is Latin for head of Medusa. Medusa was a character in mythology who had snakes for hair. It describes the appearance of distended and engorged paraumbilical veins, which are seen radiating from the umbilicus across the abdomen to join the systemic veins. Unfortunately, he continued drinking heavily and over the last year of care, he started taking oxazepam regularly, but without a prescription and at unknown doses. Table 7 includes specific recommendations for the screening and management of select complications of cirrhosis.7,9,43,45,46,49,5355, Ascites, which develops in 5% to 10% of patients with cirrhosis per year, leads to decreased quality of life, frequent hospitalizations, and directly increases risk of further complications such as spontaneous bacterial peritonitis, umbilical hernias, and respiratory compromise. government site. Clipboard, Search History, and several other advanced features are temporarily unavailable. The next day while still in the hospital, he took a shower, causing the pressure bandage to come loose, resulting in a torrent of blood rushing out of one of the umbilicus vessels. Kuniholm MH, Lesi OA, Mendy M, et al. Caput medusae is the appearance of distended and engorged superficial epigastric veins, which are seen radiating from the umbilicus across the abdomen. A conspicuous whorl of large veins sometimes seen radiating from the navel in CIRRHOSIS of the liver. Digestive Disorders Health Center Reference, Digestive Disorders Health Center Slideshows, Digestive Disorders Health Center Quizzes. This article updates previous articles on this topic by Starr and Raines,56 Heidelbaugh and Bruderly,57 and Riley and Bhatti.58. Sweden. Caput is the Latin for head, and the sign literally translates as head of Medusa 4. This site needs JavaScript to work properly. The site is secure. Chirurg. We recently encountered an interesting patient of alcoholic liver disease with two classical signs of the disease and report the same for this unusual presentation. Tiribelli C, Rigato I. Liver cirrhosis and pregnancy. Liver transplant. (2007) ISBN: 9780553590128 -, bunch of grapes sign (botryoid rhabdomyosarcoma), bunch of grapes sign (intracranial tuberculoma), bunch of grapes sign (intraosseous hemangiomas), bunch of grapes sign (multicystic dysplastic kidney). This information should not be considered complete, up to date, and is not intended to be used in place of a visit, consultation, or advice of a legal, medical, or any other professional. This content is owned by the AAFP. The visible caput medusae may not cause any pain or discomfort. To enter and activate the submenu links, hit the down arrow. Hassoun Z, PomierLayrargues G, Lafortune M, et al. The appearance is reminiscent of the hair of Medusa, Tsoris A, Marlar CA. Unable to process the form. An official website of the United States government. Cirrhosis is characterized by hepatic parenchymal necrosis and an inflammatory response to the underlying cause. Ferraioli G. Review of Liver Elastography Guidelines. The Epidemiology of Cirrhosis in the United States: A Population-based Study.. Yoon, Chen. A transjugular intrahepatic portosystemic shunt is considered potentially lifesaving. Your doctor will give you medication to slow the bleeding. Newer research has established that liver fibrosis is a dynamic process and that even early cirrhosis is reversible.11 Studies have demonstrated biopsy-proven fibrosis improvement rates as high as 88% after antiviral treatment in patients with HBV and HCV and as high as 85% after bariatric surgery in patients with nonalcoholic steatohepatitis.12,13, After cirrhosis is established, a patient may remain clinically stable, or compensated, for years. Caput medusa is a well-known complication of portal hypertension, characterized by dilated, tortuous periumbilical veins due to portosystemic connections. Sterling RK, Lissen E, Clumeck N, et al. The .gov means its official. Inclusion in an NLM database does not imply endorsement of, or agreement with, Clipboard, Search History, and several other advanced features are temporarily unavailable. If you suspect you have internal bleeding, seek immediate medical help. Ge PS, Runyon BA. A biopsy is the method of choice for confirming the diagnosis; however, it is usually only performed if the results from other diagnostic modalities are inconclusive. Patients with cirrhosis are usually either asymptomatic with incidental abnormal findings on laboratory studies or imaging, or present late with features of decompensated cirrhosis. When the portal vein is blocked, the blood volume increases in the surrounding blood vessels, and they turn into varicose veins. More commonly, portal vein hypertension is a symptom of liver damage. Further evaluation of patients with clinical signs or symptoms of liver disease or abnormal liver function tests should be pursued to determine the potential etiology, regardless of duration of the abnormality. You may also experience: Bleeding in the gastrointestinal tract: If the swollen veins rupture and cause internal bleeding, it is called bleeding varices. Biggins SW, Angeli P, GarciaTsao G, et al. Thats the vein that moves blood from your digestive tract to your liver. Zhonghua Gan Zang Bing Za Zhi. It describes the appearance of distended and engorged paraumbilical veins, which are seen radiating from the umbilicus across the abdomen to join the systemic veins. CT without contrast (axial) shows protruding paraumbilical veins, CT without contrast (coronal) shows dilated paraumbilical veins, MeSH Treatment goals are preventing cirrhosis, decompensation, and death. When chronic liver disease is suspected, a history should be conducted, reviewing any potentially hepatotoxic medications, alcohol consumption, and family history of liver disease. Alcoholic liver cirrhosis leads to portal venous hypertension, which can result in a caput medusae formation. WebCirrhosis, also known as liver cirrhosis or hepatic cirrhosis, Caput medusae are dilated paraumbilical collateral veins due to portal hypertension. It is the late stage of progres" Baywatchneverdyes on Instagram: "C I R R H O S I S (and its emergencies) What is Other nonspecific changes Other vascular findings include corkscrew scleral vessels and bier spots. A transjugular intrahepatic portosystemic shunt is considered potentially lifesaving. Careers. CT without contrast (axial) shows protruding paraumbilical veins, CT without contrast (coronal) shows dilated paraumbilical veins. WebThe caput medusae sign is seen in patients with severe portal hypertension. Liver Disease in Patients with Hereditary Hemorrhagic Telangiectasia. It describes the appearance of distended and engorged paraumbilical vei Cirrhosis with evidence of The management of acute or refractory complications of cirrhosis (e.g., spontaneous bacterial peritonitis, acute gastrointestinal bleeding, hepatorenal syndrome, unresponsive portal hypertension, hepatic encephalopathy, ascites) is best addressed in the inpatient or referral setting. Abdominal Caput medusae - dilated radiating veins around the umbilicus. 8600 Rockville Pike [Esophageal variceal bleeding: management and tips on transjugular intrahepatic portosystemic shunt]. Gao X, Zhu Y, Liu H, Yu H, Wang M. Maternal and fetal outcomes of patients with liver cirrhosis: a case-control study. Generally, noninvasive tests are most useful in identifying patients with no to minimal fibrosis or advanced fibrosis. If risk factors for NAFLD exist, testing of fasting lipid levels and A1C should be done. Cirrhosis-associated ascites and edema and elevated bleeding risk increase the risk for hypovolemic shock. Veterans Crisis Line: Spectrum of Liver Disease in Type 2 Diabetes and Management of Patients With Diabetes and Liver Disease. They may also perform: The treatment for caput medusae depends on what other symptoms you have and the underlying causes of them.. Alcoholic liver cirrhosis leads to portal venous hypertension, which can result in a caput medusae formation. Management consists of treatment of the underlying disease (e.g., avoidance of toxic substances, antiviral drugs), adequate calorie intake, and medication for treating complications (e.g., spironolactone for ascites). Diagnosis and Treatment of AlcoholAssociated Liver Diseases: 2019 Practice Guidance From the American Association for the Study of Liver Diseases. Webportal hypertension associated with liver cirrhosis can present as a dilated vein on the surface of the abdominal wall; this is called caput medusae. Chronic liver injury causes inflammation and hepatic fibrosis. Patients with cirrhosis who have medium, large, or high-risk varices (red wale markings) should be treated with nonselective beta blockers and/or endoscopic band ligation for primary prevention of variceal bleeds. When you go for an appointment, your doctor will need to determine the cause of the blockage in your portal vein. Melas N, Haji Younes A, Magnusson P. A case of fatal cutaneous caput medusae hemorrhage. His wife had found him lying on the floor with impaired consciousness and copious amounts of blood spurting from a distended vessel in the umbilical area. TIPS is considered the most important part of management and potentially lifesaving. Patients with cirrhosis can be asymptomatic (compensated cirrhosis). Patients with varices have a one in three chance of developing a variceal bleed in the two years after diagnosis, with a 20% to 40% mortality rate per episode.45 Endoscopy is the preferred screening method for esophageal varices. > CHILD's ABCDEs: Albumin, Bilirubin, Coagulation (i.e., INR), Distended abdomen (i.e., ascites), and Encephalopathy. FOIA doi: 10.1136/bcr-2021-242076. Fisher L, Fisher A. Vitamin D and Parathyroid Hormone in Outpatients With Noncholestatic Chronic Liver Disease. Sangster GP, Previgliano CH, Nader M, Chwoschtschinsky E, Heldmann MG. MDCT Imaging Findings of Liver Cirrhosis: Spectrum of Hepatic and Extrahepatic Abdominal Complications. The most common causes of cirrhosis in the United States are hepatitis C, alcohol-associated liver disease, and nonalcohol-associated liver disease, which CAPUT MEDUSAE: Prominent superficial abdominal veins seen on a patient with cirrhosis and portal hypertension. Copyright 2019 by the American Academy of Family Physicians. A person viewing it online may make one printout of the material and may use that printout only for his or her personal, non-commercial reference. According to the medical records from the general practitioner who visited patients home and confirmed his death, the patient was about as usual the evening before. Swelling of the legs and belly due to fluid build-up in the body; Belly button sticks out; Enlarged spleen; Humming sound of the Vitamin K infusion may improve clotting function in select patients with vitamin K deficiency; it is unlikely to be effective in patients with advanced liver disease and coagulopathy. Received 2018 Sep 20; Revised 2018 Nov 21; Accepted 2018 Dec 15. The diagnosis of cirrhosis can be reached on the basis of established hepatic morphological changes. Gastroenterol Clin North Am. WFUMB Guidelines and Recommendations for Clinical Use of Ultrasound Elastography: Part 3: Liver. [42]. visit VeteransCrisisLine.net for more resources. During hospitalization, he underwent esophagogastroduodenoscopy (EGD) that revealed signs of ALCdecompensation with grade 2 esophageal varices and portal hypertensive gastropathy. WebCaput medusae. Platelet transfusion should be performed to maintain a level above 50109/L.23 Lowering portal venous hypertension reduces portosystemic variceal pressure with a resulting reduction in the risk of hemorrhage. Cales P, Desmorat H, Vinel JP, et al. Making the diagnosis of cirrhosis will affect management and follow-up. Krok KL. TIPS is considered being the cornerstone of interventional treatment. Newer guidelines suggest targeted screening for esophageal varices in patients with clinically significant portal hypertension rather than screening all patients with cirrhosis. 2) [1, 4]. (one of the two most common causes of chronic, (most common cause of cirrhosis in the United States), has been identified as a central element for developing, The following three mechanisms have been described for all types of, Changes in the hepatic metabolization of sex, , resulting in a marked increase in systemic, caused by an accumulation of dimethyl sulfide, Patients with cirrhosis are usually either asymptomatic with incidental abnormal findings on, abnormalities are due to the combination of, Atrophies and shrinks with disease progression, ), increased portosystemic collateral flow, In cases of diagnostic uncertainty (gold standard), depending on the presence and size of the, Primarily used to prioritize patients for, A prognostic grading scale that assesses survival rate and predicts the likelihood of developing complications, Screen for, recognize, and treat complications. Progressive fibrosis and cirrhosis subsequently result in decreased metabolic and synthetic hepatic function, causing a rise in bilirubin and decreased production of clotting factors and thrombopoietin, as well as splenic platelet sequestration, increased portal pressure, and the development of ascites and esophageal varices. 8600 Rockville Pike The primary goals of liver disease management are to prevent cirrhosis complications, liver decompensation, and death. Transient elastography performs better than the biomarker-based tools in detecting cirrhosis and is accurate at excluding cirrhosis (negative predictive value greater than 90%).38 Similar to serum tests, however, transient elastography is less accurate at distinguishing between intermediate stages of liver disease, and cutoff values vary depending on the etiology of liver disease and population studied.24,38, Abnormal serum results may be seen from nonliver-related causes, including bone marrow disease, hemolysis, and medications. Only 10days after discharge from the hospital, he was readmitted for severe bleeding from a superficial epigastric vein. Federal government websites often end in .gov or .mil. Abdominal pain and elevated liver enzymes. and transmitted securely. Karolinska Institutet, They are typically painless, but they are a symptom of circulatory problems that are often related to liver disease.. Multiple lienorenal and gastrosplenic varices. Rockey DC, Caldwell SH, Goodman ZD, Nelson RC, Smith AD. At the time the article was created Mohammadtaghi Niknejad had no recorded disclosures. The median survival for those with compensated cirrhosis is 12 years, compared with two years once decompensation occurs.15. Regardless of the cause, this can lead to the formation of fibrous septae and nodules, collapse of liver structures, and distortion of hepatic parenchyma and vascular architecture. Arch Sci Med (Torino). Smith A, Baumgartner K, Bositis C. Cirrhosis: Diagnosis and Management.. Wiegand J, Berg T. The Etiology, Diagnosis and Prevention of Liver Cirrhosis. This patient underwent only suture ligation, and he had a fatal recurrent bleeding after one month. The term caput medusae comes from the serpentine appearance of the dilated epigastric veins, which resembles the head (Latin, caput) of the gorgon Medusa in Greek mythology, described as a human female whom the goddess Athena transformed into a monster with venomous snakes in place of hair.9 The majority of variceal hemorrhage is related to gastroesophageal varices, with approximately 50% mortality for the initial hemorrhage, but high rates of control, up to 90%, depending on the therapeutic intervention.10, 11 In spite of the prevalence of caput medusae, massive cutaneous hemorrhage from this area seems extremely rare with only two fatal cases12, 13 and six other nonfatal cases14, 15, 16, 17, 18, 19 reported in the literature to our knowledge. Careers. PMC Industrial chemicals such as tetrachloromethane, Cirrhosis is characterized by irreversible diffuse. Additionally, fat containing umbilical hernia is present accompanied by recanalization of umbilical vein causing caput medusae sign. Who's Who in the Ancient World. Sign up and get unlimited access. Caput medusae is the name for a cluster of swollen veins in your abdomen. Wu M, Schuster M, Tadros M. Update on Management of Portal Vein Thrombosis and the Role of Novel Anticoagulants. Prothrombin complex concentrate is seldom used in patients with liver cirrhosis due to an elevated risk of thrombosis and lack of evidencebased favorable outcome. The site is secure. You will now be able to tab or arrow up or down through the submenu options to access/activate the submenu links. A transjugular intrahepatic portosystemic shunt is considered potentially lifesaving. Kwo PY, Cohen SM, Lim JK. Author disclosure: No relevant financial affiliations. An official website of the United States government. -, Grace ND. Sze DY, Magsamen KE, McClenathan JH, et al. Caput medusa is a sign of portal hypertension in that it shows these varices are forming. Become a Gold Supporter and see no third-party ads. Cho K, Patel Y, Wachsberg R, Seeff J. Varices in Portal Hypertension: Evaluation with CT. Radiographics. For those with clinical signs or symptoms of liver disease or abnormal liver function test results, regardless of duration, further evaluation to determine the potential etiology should be pursued promptly. -, Lebrec D, Benhamou JP. 2005 - 2023 WebMD LLC, an Internet Brands company. ADVERTISEMENT: Supporters see fewer/no ads. Blood analysis showed a spontaneously elevated international normalized ratio (INR), hypoalbuminemia, elevated liver enzymes, and anemia. All content on this website, including dictionary, thesaurus, literature, geography, and other reference data is for informational purposes only. We believe that surgical suture should be considered only as bridging to definitive therapy with TIPS. Doctors will place a tube, called a shunt, in your abdomen to divert most of the blood that would normally go to the liver. WebCaput medusae; Other names: Palm tree sign: Axial CT showing portosystemic collateral circulation via the umbilical vein: caput medusae in liver cirrhosis: Specialty: Biomarkers are most validated in chronic HCV,40 with the exception of the NAFLD fibrosis score for non-alcoholic steatohepatitis.33 For other etiologies of liver disease, including alcoholic liver disease, few studies of noninvasive methods exist. Exsanguinating hemorrhage from a caput medusae: cutaneous variceal bleeding, Fatal haemorrhage from a caput medusae: a differential to a stabbing. The area was sutured closed under local anesthesia and the bleeding stopped. Uppsala University/Region Gvleborg, 2. Table 3 lists additional suggested tests based on risk factors and clinical findings.19,21,22, Liver fibrosis is scored on a scale from F0 to F4 (Table 4).23 Differentiating between significant (F2 or greater) and advanced (F3 or greater) fibrosis and cirrhosis (F4) is difficult even with complete clinical, laboratory, and imaging data because findings are often nonspecific or insensitive.24 Liver biopsy remains the reference standard for assessing liver fibrosis; however, use of noninvasive methods has become increasingly common in clinical practice.18, Noninvasive testing includes serum-based and imaging modalities (Table 52537). All authors declared no conflict of interest. The root cause of caput medusae is portal hypertension, which is an increase in pressure in the portal vein. Instead, it will flow to another part of your circulatory system. Cirrhosis is a condition caused by chronic damage to the liver, most commonly due to excessive alcohol consumption, nonalcoholic fatty liver disease, or hepatitis C. Other causes include inflammatory or metabolic diseases, such as primary biliary cirrhosis and hemochromatosis. These studies may help to identify the underlying etiology and further evaluate liver function. and transmitted securely. Hepatology. Accessibility History and etymology Caput is the Latin for head, and the sign literally translates as head of Medusa 4. The Greek Myths. In patients with the three most common causes of liver disease, 10% to 20% will develop cirrhosis within 10 to 20 years.9 Factors associated with an increased risk of progression to cirrhosis include increased age, medical comorbidities (particularly patients coinfected with HIV and HCV), and male sex (except in alcoholic liver disease, where females progress more rapidly).10 The point at which this process becomes irreversible, however, is not clear. If performed during an episode of acute hepatic inflammation, these tests can also lead to falsely elevated results.38. Liver transplantation in patients with alcoholic liver disease: a retrospective study. Chronic portal hypertension increases the distension of these vessels, which also increases their propensity to rupture. DAmico G, Bernardi M, Angeli P. Towards a new definition of decompensated cirrhosis. WebMD does not provide medical advice, diagnosis or treatment. We list the most important complications. 1. It is crucial to stop the bleeding promptly. TIPS to the rescue: Preoperative Transjugular Intrahepatic Portosystemic Shunt (TIPS) placement in a patient with caput medusae and colon cancer. Cirrhosis is a diffuse process of liver damage considered irreversible in its advanced stages. Clin Case Rep. 2019;7:452455. ADVERTISEMENT: Radiopaedia is free thanks to our supporters and advertisers. Development of a simple noninvasive index to predict significant fibrosis in patients with HIV/HCV coinfection. Transjugular intrahepatic portosystemic stent shunt placement and embolization for hemorrhage associated with rupture of anorectal varices. Call: 988 (Press 1), U.S. Department of Veterans Affairs | 810 Vermont Avenue, NW Washington DC 20420. The volume of blood that was found all over the body, his clothes, in the bed, and on the floor was large, possibly a few liters. This site needs JavaScript to work properly. Ponziani FR. Indian Journal of Medical Research: Caput medusae.. FOIA The selection is not exhaustive. The peripheral stigmata of chronic liver disease are not routinely seen now a days due to early diagnosis and better therapy. If you have caput medusae, you should speak to a doctor. He was also strongly advised to abstain from alcohol. MeSH Alcoholic liver disease. 1992 Jan-Feb;10(1):19-23. doi: 10.1016/0736-4679(92)90005-e. Rosenfeld H, Hochner-Celnikier D, Ackerman Z. Eur J Gastroenterol Hepatol. If your portal hypertension is caused by severe liver damage, you may be a candidate for a liver transplant. He stated he had not adhered to his prescribed medications and that he had only been taking ferrous sulfate. For those with clinical signs or symptoms of liver disease or abnormal liver function test results, regardless of duration, further evaluation to determine the potential etiology should be pursued promptly.19,20 Viral hepatitis serologies, ferritin, transferrin saturation, and abdominal ultrasonography should be performed; complete blood count, liver function tests, and PT/INR should be completed, if not already ordered. Newer research has established that liver fibrosis is a dynamic process and that early cirrhosis may be reversible. With an increasing prevalence of nonalcoholic fatty liver disease (NAFLD) in the United States, estimates suggest that non-alcoholic steatohepatitis, a severe progression of NAFLD characterized by inflammatory steatohepatitis, will become the leading cause of cirrhosis in patients awaiting liver transplant sometime between 2025 and 2035.6,7 Table 1 lists common etiologies of cirrhosis.8. Abdominal ultrasound examination confirmed signs of liver cirrhosis. J Assoc Physicians India. Men may also display signs of feminization (e.g., gynecomastia, hypogonadism). Vavricka SR, Burri E, Beglinger C, Degen L, Manz M. Serum Protein Electrophoresis: An Underused but Very Useful Test. Careers, Unable to load your collection due to an error. One month later, the patient's wife summoned help because she thought he had died. Liver chemistries may be normal in early compensated cirrhosis. The visible caput medusae may not cause any pain or discomfort. Portal hypertension and liver disease have other noticeable symptoms in addition to distended veins. You may also experience: Bleeding in the gastrointestinal tract: If the swollen veins rupture and cause internal bleeding, it is called bleeding varices. Disclaimer. Search dates: November 26, 2018; December 27, 2018; and August 7, 2019. Ascites treatment includes diuresis, salt restriction, and antibiotic prophylaxis for spontaneous bacterial peritonitis, when indicated. This relieves the pressure in the portal vein. (histological staging is based on the size of the regenerative nodules). Keywords: Abdominal swelling. Alcohol. Hepatorenal Syndrome. This page was last edited on 4 May 2023, at 08:13. Medusa was encountered and beheaded by the Greek demigod hero Perseus 2,3. Budd-Chiari syndrome is a type of hepatic venous In severe cases, the accumulation of toxic metabolites or involvement of additional organs can lead to complications such as hepatic encephalopathy and hepatorenal syndrome (HRS). His treatment consisted of a daily dose of omeprazole 20mg, aldactone 100mg, propranolol 40mg, furosemide 40mg, sodium picosulfate 5mg, insulin lispro 4 units as needed, and oxazepam 5mg as needed. Initial workup includes viral hepatitis serologies, ferritin, transferrin saturation, and abdominal ultrasonography as well as complete blood count, liver function tests, and prothrombin time/international normalized ratio, if not already ordered. It is crucial to stop the bleeding promptly. Disclaimer. Please switch auto forms mode to off. Your doctor will tell you if you need to consider this option. Diagnosis, Evaluation, and Management of Ascites, Spontaneous Bacterial Peritonitis and Hepatorenal Syndrome: 2021 Practice Guidance by the American Association for the Study of Liver Diseases. When clinical signs, symptoms, or abnormal liver function tests are discovered, further evaluation should be pursued promptly. Gynecomastia and cirrhosis of the liver. Disease progression leads to fatigue, weight loss, abdominal distention, and spider angiomata followed by decompensated cirrhosis, manifesting with bleeding varices, ascites, encephalopathy, and jaundice. Encephalopathy: Poor liver function can cause confusion and memory issues. government site. Normally opacified portal, SMV and splenic veins. Cardiology Research Unit, Department of Medicine, Oral antibiotic prophylaxis against spontaneous bacterial peritonitis should be initiated in patients with a history of spontaneous bacterial peritonitis or ascitic fluid protein < 1.5 g per dL (15 g per L) and advanced liver disease (Child-Pugh score 9 or bilirubin 3 mg per dL) or kidney disease (serum creatinine 1.2 mg per dL, serum sodium 130 per mmol per L). Your doctor will also probably need to perform an endoscopy to locate the source of the bleeding and make sure it is stopping. WebThis is a medical emergency. Talk to your doctor before taking any new medications to make sure they wont harm your liver further. Massive bleeding from ectopic varices in the postpartum period: rare but serious complication in women with portal hypertension. EASL Clinical Practice Guidelines for the management of patients with decompensated cirrhosis. Ferraioli G, Filice C, Castera L, et al. WebIntroduction THE formation of a [quot] caput medusae [quot] around the umbilicus is a complication of portal hypertension in patients with cirrhosis of the liver. Treat bleeding. It may be seen in newborns. eCollection 2020 Sep. Fitzgerald JB, Chalmers N, Abbott G, Lee SH, Warnes TW, Youngs GR, Wardle TD. Hit enter to expand a main menu option (Health, Benefits, etc). You may have symptoms including black, tarry stools or blood in the stools. Primignani M. Portal vein thrombosis, revisited. Identifying the presence of cirrhosis is essential in any patient with chronic liver disease. BMJ Case Rep. 2021 Apr 26;14(4):e242076. (2017) ISBN: 9780241982358 -, 3. A computerized tomography of the abdomen showed dilatation of the paraumbilical veins (Figures (Figures11 and and2).2). Varicose veins are also more fragile than typical veins and prone to bleeding. anatomical terminology for the expanded or chief extremity of an organ or part. https://medical-dictionary.thefreedictionary.com/caput+medusae. Patients with cirrhosis and some with chronic HBV should undergo right upper quadrant ultrasonography every six months to screen for hepatocellular carcinoma. It is crucial to stop the bleeding promptly. 2014 Dec;29(12):1952. doi: 10.1111/jgh.12802. The caput medusae sign is most commonly detected during clinical examination of patients with advanced cirrhosis. Local measures with direct pressure, suture ligation, or cautery, and correction of coagulopathy should be applied early in resuscitation. Now, he had developed liver encephalopathy and was discharged with the instruction that he take lactulose 20g twice daily and ferrous sulfate 100mg twice daily. Unable to load your collection due to an error, Unable to load your delegates due to an error. Check for errors and try again. The Gorgons had venomous snakes for hair and their countenance was said to be so terrifying that anyone who looked upon them was literally turned to stone. Symptoms of Caput Medusae. Incidentally elevated liver enzymes or evidence of hepatic disease on imaging may prompt the initial suspicion of chronic liver injury. 2013 Aug;61(8):564. Based on the patient's medical history and prior similar episodes of bleeding at the umbilicus area, the physician determined the cause of death to be fatal bleeding from the caput medusae. Procopet B, Berzigotti A. Sweden, 2 The appearance is reminiscent of the hair of Medusa, one of the three Gorgons of Greek mythology. After pushing down on the prominent vein, blood will: Language links are at the top of the page across from the title. Treatment of this condition includes standard resuscitation protocols as an initial approach in order to obtain hemodynamic stabilization with local measures to control the bleeding during the resuscitation, such as direct pressure, suture ligation, or cautery.20, 21, 22 Other measures in the management of caput medusae hemorrhage are the correction of coagulopathy and the reduction of portal hypertension. 1.5 mg/dL (very non-specific), Enlarged caudate lobe/left lobe of the liver, Cutoffs are different for different etiologies of cirrhosis, Other methods to measure liver stiffness include acoustic radiation force impulse (ARFI) and magnetic resonance elastography (MRE), but they are not point-of-care. Newer research has established that liver fibrosis is a dynamic process and that early cirrhosis may be reversible. ADVERTISEMENT: Radiopaedia is free thanks to our supporters and advertisers. Fitzgerald JB, Chalmers N, Abbott G, et al. Federal government websites often end in .gov or .mil. If you have liver disease, your doctor will suggest changes to your diet and lifestyle to minimize your symptoms. Physical examination findings that may be present in patients with advanced liver disease (cirrhosis) are summarized in Table 2.16,17 The Stanford Medicine 25 website is a good resource for photos and instructional videos that demonstrate findings associated with cirrhosis (http://stanfordmedicine25.stanford.edu/the25/liverdisease.html).16,17, In early compensated disease, laboratory findings may be normal. Attention A T users. Before After discharge from the hospital, he was followed regularly in our gastroenterology unit. However, tortuous collaterals around the umbilicus can be classically described on abdominal ultrasound, CT or MRI during evaluation of patients with portal hypertension of any origin (Fig. Underlying cause of death 1999-2018 on CDC WONDER online database.. Mansour D, McPherson S. Management of decompensated cirrhosis.. Ng CK, Chan MH, Tai MH, Lam CW. WebCaput medusae and palmar erythema are cardinal signs in cirrhosis of liver with portal hypertension. Modification may be required based on clinical features and the presence of risk factors. Office of Accountability & Whistleblower Protection, Training - Exposure - Experience (TEE) Tournament, War Related Illness & Injury Study Center, Clinical Trainees (Academic Affiliations), Call TTY if you NM: involved in idea, design, data collection, major writing, and project management. Patients with a Model for End-Stage Liver Disease score of 15 or higher should be referred for liver transplantation evaluation37,45; patients with ascites, hepatic encephalopathy, or variceal hemorrhage should also be referred.37,53, Patients with cirrhosis are at risk of multiple complications, including hepatic decompensation, hepatocellular carcinoma, and other more common conditions (e.g., malnutrition, leg cramps, umbilical hernias). HHS Vulnerability Disclosure, Help All authors approved the final version of the case report for submission to the Clinical Case Reports. Please enable it to take advantage of the complete set of features! Patients with cirrhosis who have a Model for End-Stage Liver Disease score of 15 or more, or complications of cirrhosis that include ascites, hepatic encephalopathy, or variceal hemorrhage, should be referred to a transplant center. Blood Cirrhosis is the 12th leading cause of death in the United States. The swelling usually appears around the belly button, and the veins branch out from a central point. It also portends a poor prognosis, with a 30% five-year survival.53 Hepatic encephalopathy, which occurs in 5% to 25% of patients within five years of a cirrhosis diagnosis, is likewise associated with increased medical cost and mortality, with a reported 15% inpatient mortality rate.54, Portal hypertension predisposes patients with cirrhosis to develop esophageal varices. Web368 likes, 1 comments - Baywatchneverdyes (@ercrackingthecode) on Instagram: "C I R R H O S I S (and its emergencies) What is cirrhosis? Would you like email updates of new search results? WebAlcoholic liver cirrhosis leads to portal venous hypertension, which can result in a caput medusae formation. Bookshelf Caput medusae, sometimes called a palm tree sign, refers to the appearance of a network of painless, swollen veins around your bellybutton. While its not a disease, it is a sign of an underlying condition, usually liver disease. Persistent hepatic encephalopathy that does not respond to conservative measures should be treated with lactulose and/or rifaximin (Xifaxan). Lifethreatening hemorrhage from a ruptured caput Br J Radiol. Cirrhosis is the 12th leading cause of death in the United States. Life-threatening hemorrhage from a ruptured caput medusae vein is a rare complication. After physical examination, the physician concluded the cause of death was massive bleeding from a ruptured caput medusae vessel. the contents by NLM or the National Institutes of Health. The use of TIPS to control bleeding caput medusae, Umbilical haemorrhage an unsusal complication of cirrhosis, Control of lifethreatening bleeding from caput medusae by umbilical vein embolization, Hemorrhage from recanalized umbilical vein in a patient with cirrhosis. Acoustic Radiation Force Impulse (ARFI) and Transient Elastography (TE) for evaluation of liver fibrosis in HIV-HCV co-infected patients. HHS Vulnerability Disclosure, Help Infusion of fresh frozen plasma (or plasma exchange, in the case of volume overload) is sometimes used but lack proven efficacy with regard to coagulation. Alcoholic liver cirrhosis leads to portal venous hypertension, which can result in a caput medusae formation. Hepatic hydrothorax: Current concepts. -, OShea RS, Dasarathy S, McCullough AJ. The site is secure. A 76yearold Caucasian male was followed in the gastroenterology unit because of alcoholic liver cirrhosis (ALC) due to a daily consumption of 0.75L of wine over the past two decades. WebCaput medusae (dilated venous pattern over the right upper abdomen) Fluid Overload: Peripheral edema Note: edema in ascites due to liver or heart disease is usually confined to the lower extremities only; if present also in upper extremities and hands, consider renal disease and nephrotic syndrome. If you have caput medusae, talk to your doctor about treatment. Treat the underlying cause and complications (if applicable). Hepatitis, alcohol abuse, or other types of liver damage cause scar tissue to form on the liver. Hepatocyte injury: AST, ALT, ALP, GGT. This material may not otherwise be downloaded, copied, printed, stored, transmitted or reproduced in any medium, whether now known or later invented, except as authorized in writing by the AAFP. Hepatitis C, alcoholic liver disease, and NASH are the most common causes of cirrhosis in the US. If the less invasive measures dont stop the bleeding or if you have repeated bleeding episodes, you may need surgery to repair the damage and reroute blood vessels. A broad range of cutaneous alterations can be present in patients with cirrhosis, such as vascular, nail, hair, hormonal changes, etc. See this image and copyright information in PMC. The caput medusae signis seen in patients with severe portal hypertension. Liver biopsy remains the reference standard in diagnosing cirrhosis; however, a 20% error rate still occurs in fibrosis staging.44 Pathologic changes may be heterogeneous; therefore, sampling error is common, and interpretation should be made by an experienced pathologist using validated scoring systems.38 Liver biopsy is recommended when concern for fibrosis remains after indeterminate or conflicting clinical, laboratory, and imaging results; in those for whom transient elastography is not suitable; or to clarify etiology of disease after inconclusive noninvasive evaluation.9 Liver biopsy may be indicated to diagnose necroinflammation (in HBV) and steatohepatitis (nonalcoholic steatohepatitis) because they are not easily distinguished by noninvasive methods. The https:// ensures that you are connecting to the Three hyperdense stones are seen in gallbladder. A little amount abdominopelvic free fluid is observed. 2017;53(2):151156. Cirrhosis is the 12th leading cause of death in the United States. AHY: involved in patient management, and critical revision. The right kidney is markedly small and shows severe parenchymal atrophic changes. They will probably ask you to stop drinking any alcohol or taking recreational drugs. Crabb DW, Im GY, Szabo G, Mellinger JL, Lucey MR. All patients with cirrhosis should be evaluated for hepatocellular carcinoma with ultrasonography every six months. The spleen is enlarged and its cephalocaudal height measured 180 mm. Sagoo MG, Aland RC, Gosden E. Morphology and morphometry of the caudate lobe of the liver in two populations.. Horowitz JM, Kamel IR, et al. Dictionary, Encyclopedia and Thesaurus - The Free Dictionary, the webmaster's page for free fun content, caput humerale musculi flexoris carpi ulnaris, caput humerale musculi pronatoris teretis, caput laterale musculi tricipitis brachii, caput obliquum musculi adductoris hallucis, caput obliquum musculi adductoris pollicis, caput transversum musculi adductoris hallucis, caput transversum musculi adductoris pollicis, caput ulnare musculi flexoris carpi ulnaris, caput humeroulnare musculi flexoris digitorum superificialis, caput inferius musculi pterygoidei lateralis, caput infraorbitale quadrati labii superioris, caput laterale musculi flexoris hallucis brevis, caput mediale musculi flexoris hallucis brevis, caput profundum musculi flexoris pollicis brevis, caput profundum musculi tricipitis brachii, caput radiale musculi flexoris digitorum superficialis, caput superficiale musculi flexoris pollicis brevis, caput superius musculi pterygoideus lateralis. Patients with decompensated cirrhosis or compensated cirrhosis and liver stiffness > 20 kilopascals (measured by transient elastography) or platelet count < 150,000 per mm, http://stanfordmedicine25.stanford.edu/the25/liverdisease.html, https://www.mdcalc.com/ast-platelet-ratio-index-apri, http://gihep.com/calculators/hepatology/fibrosis-4-score/, https://www.mdcalc.com/child-pugh-score-cirrhosis-mortality, https://www.mdcalc.com/meld-score-model-end-stage-liver-disease-12-older, https://www.mayoclinic.org/medical-professionals/transplant-medicine/calculators/post-operative-mortality-risk-in-patients-with-cirrhosis/itt-20434721/?vp=MPG-20426275, Expert opinion and consensus guidelines in the absence of clinical trials, Expert opinion and consensus guidelines with low-quality trials, Randomized controlled trials demonstrate acceptable survival benefits based on clinical criteria and Model for End-Stage Liver Disease results with some variability, Data from multiple randomized controlled trials demonstrate more benefit than harm regarding patient comfort and reduced hospitalization times, Randomized controlled trials and meta-analyses comparing nonselective beta blockers, endoscopic band ligation, and placebo or no therapy, which generally show a reduction in variceal hemorrhage, Low-quality randomized controlled trials that demonstrate less recurrence of hepatic encephalopathy using lactulose and/or rifaximin, Multiple randomized controlled trials demonstrate a reduction in bacterial infections as well as mortality, Expert opinion, consensus guidelines, and unpublished studies in progress, Viral hepatitis (hepatitis B, hepatitis C), Nonalcoholic fatty liver disease/nonalcoholic steatohepatitis, Veno-occlusive disease (Budd-Chiari syndrome), Hereditary hemorrhagic telangiectasia (Osler-Weber-Rendu disease), Medications (e.g., methotrexate, amiodarone), Asterixis (tremor of the hand with wrist extension), Fetor hepaticus: sweet odor of the breath attributable to increased concentrations of dimethyl sulfide, Jaundice: may see yellowing of mucous membranes beneath the tongue, Caput medusae (engorged superficial epigastric veins radiating from the umbilicus), Dupuytren contracture (progressive fibrosis of palmar fascia, resulting in limited extension of the fingers), Terry nails (whiteness of proximal half of nail plate), Positive screening tests for alcohol use disorder, Aspartate transaminase 2 times alanine transaminase level in 70% of patients, especially if 3 times, Elevated glucose tolerance test and/or mean corpuscular volume [corrected], Young and middle-aged women (in type 1, the most common), Antinuclear antibody and/or antismooth muscle antibody positive in titers 1:80, Total serum immunoglobulin G (polyclonal hypergammaglobulinemia > 1.5 times the upper limit of normal supports diagnosis), Ferritin 250 to 300 ng per mL in men, 200 ng per mL in women, Transferrin saturation (serum iron 100/total iron-binding capacity) 45%, If ferritin or transferrin saturation is abnormal, order human hemochromatosis protein gene mutation analysis, May need biopsy to diagnose nonalcoholic steatohepatitis, Primary biliary cholangitis (primary biliary cirrhosis), Associated with other autoimmune disorders (80% with Sjgren syndrome; 5% to 10% with autoimmune hepatitis), Cholestasis (elevated alkaline phosphatase and glucose tolerance test), Associated with inflammatory bowel disease (70%), Perinuclear antineutrophil cytoplasmic antibodies positive in 70% of patients, If either is positive, order hepatitis B virus DNA, Specific risk factors for hepatitis C virus, Age younger than 40 years with chronic liver disease or fatty liver and negative workup for the above, If abnormal, serum copper, urinary copper excretion, liver biopsy, hepatic tissue copper measurement, and genetic marker testing can be considered, Positive scarring with extension beyond area containing blood vessels, Bridging fibrosis with connection to other areas of fibrosis, < 0.5: good NPV (80% in HCV) for significant fibrosis, > 2.0: high specificity for cirrhosis in HCV (46% sensitivity, 91% specificity), < 1.45: good NPV (95% in HCV) for advanced fibrosis, > 3.25 (range: 2.67 to 3.60): good PPV for advanced fibrosis/cirrhosis in HCV, HBV, and NAFLD, In HCV with 3.25, PPV for advanced fibrosis = 82%, In NAFLD with 2.67, PPV for advanced fibrosis = 80%, < 0.30: good NPV (90%) for advanced fibrosis in NAFLD, > 0.48: high specificity for significant fibrosis in HCV (specificity = 85%), > 0.70: high specificity for advanced fibrosis or cirrhosis, In NAFLD with > 0.70, PPV for advanced fibrosis = 73%, In HBV with > 0.74, specificity for cirrhosis = 91%, Age, body mass index, AST, ALT, glucose, platelets, albumin, < 1.455: good NPV (88%) for advanced fibrosis in NAFLD, > 0.676: good PPV (82%) for advanced fibrosis in NAFLD, HCV (> 12.5 kPa): high sensitivity (87%) and specificity (91%) for cirrhosis; very accurate for F2 to F4 when combined with FibroTest, HBV (> 9.0 to 12.0 kPa): good sensitivity (83%) and specificity (87%) but may be falsely elevated during flare-up, NAFLD (> 10.3 kPa): good NPV (98.5%) but lower PPV (56%), Hepatic nodularity specific for severe fibrosis or cirrhosis in all forms of liver disease (sensitivity = 54%, specificity = 95%), Evidence of portal hypertension (splenomegaly, portosystemic collaterals), Brief physician counseling, behavioral counseling, and group support, Medication-assisted treatment for alcohol use disorder, Avoid naltrexone and acamprosate in patients with Child-Pugh grade C cirrhosis, Baclofen (Lioresal), 5 mg three times daily for three days, then 10 mg three times daily can be used, even with ascites, Avoidance of unnecessary surgical procedures, Cirrhosis, especially if decompensated or with Model for End-Stage Liver Disease score 14, increases perioperative mortality risk, Three to four cups of coffee per day may reduce the risk of hepatocellular carcinoma and fibrosis progression in patients with nonalcoholic fatty liver disease and hepatitis C virus infection, Infection prevention: bacterial exposures, Avoid exposure to brackish/salt water and consumption of raw seafood (, Avoid unpasteurized dairy (risk of serious, All patients with liver disease should receive yearly influenza vaccinations and hepatitis A and B vaccinations if not known to be immune, In patients with cirrhosis and chronic hepatitis B virus infection, 23-valent pneumococcal polysaccharide vaccine (Pneumovax 23) is recommended, Analgesics: acetaminophen preferred, limit to 2 g per day 7; nonsteroidal anti-inflammatory drugs contraindicated, Antihypertensives: discontinue if patient has hypotension or ascites (linked to hepatorenal syndrome and mortality), Aspirin: low-dose aspirin may be continued if cardiovascular disease severity exceeds the severity of cirrhosis, Metformin: should be continued for patients with diabetes mellitus, Proton pump inhibitors: avoid unnecessary use (linked to increased risk of spontaneous bacterial peritonitis), Sedating medications: avoid benzodiazepines and opiates, especially in hepatic encephalopathy; hydroxyzine or trazodone may be considered for severe insomnia, Supplements: avoid daily dosage of vitamin A > 5,000 IU (may increase fibrosis production); avoid multivitamins with iron, Maximize obesity and diabetes management because they increase the risk of cirrhosis, Weight loss of 10% improves histopathologic features of nonalcoholic steatohepatitis, including fibrosis, Screening for and treatment of underlying causative factors of liver disease, Treatment of alcohol use disorder, chronic hepatitis B or C virus infection, and nonalcoholic fatty liver disease can prevent progression and complications of liver disease and can improve fibrosis levels, even in patients with cirrhosis, Defer surgery until medically optimized and ascites controlled, High perioperative risk and hernia recurrence in presence of ascites, Surgeon with experience in the care of patients with cirrhosis is best. The patient refused to stay in the hospital and was discharged the next day. You may need to go on a low sodium diet. Jameson JL, Fauci AS, Kasper DL, Hauser SL, Longo DL, Loscalzo J. Meseeha M, Attia M. Alpha 1 Antitrypsin Deficiency. Caput medusa: a sign of portal hypertension in case of chronic Budd-Chiari syndrome. PMC You may have symptoms including black, tarry stools or blood in the stools. Atypical blood count. -. An autopsy was deemed unnecessary. Blood from the portal venous system may be forced through the paraumbilical veins and ultimately to the abdominal wall veins. When the physician removed the bandage from the vessel and compressed the abdomen on the caput medusae, dark blood poured out from an opening in one of the vessels of the caput medusae. Most deaths occur in the fifth to sixth decade of life. 1 Common serum and ultrasound-based screening tests to assess fibrosis include the aspartate transaminase to platelet ratio index score, Fibrosis 4 score, FibroTest/FibroSure, nonalcoholic fatty liver fibrosis score, standard ultrasonography, and transient elastography. It is crucial to stop the bleeding promptly. Centre for Research and Development, HHS Vulnerability Disclosure, Help Due to portal hypertension, these venous collaterals are at higher venous pressures and at risk of significant bleeding with minimal trauma. Unable to process the form. Nusrat S. Cirrhosis and its complications: Evidence based treatment. Patients with compensated cirrhosis caused by HBV, HCV, and alcoholic liver disease develop clinical signs of decompensation, which include ascites, hepatic encephalopathy, jaundice, or bleeding, at a rate of 4% to 10% per year.14 Variability of disease progression is influenced by the underlying cause and the presence or absence of treatment and ongoing liver injury. WebCaput medusae is a network of dilated veins surrounding the umbilicus. When symptoms occur, they include fatigue, weakness, loss of appetite, right upper quadrant discomfort, and unexplained weight loss. Webcaput medusae. Epub 2018 Jan 17. J Emerg Med. The PubMed wordmark and PubMed logo are registered trademarks of the U.S. Department of Health and Human Services (HHS). Krowka MJ, Fallon MB, Kawut SM, et al. Intensive observation is required, as these patients are at high risk for both complications and recurrent bleeding. [1] It is caused by dilation of the paraumbilical veins, which carry oxygenated blood from mother to fetus in utero and normally close within one week of birth, becoming re-canalised due to portal hypertension caused by liver failure. ANDREW SMITH, MD, KATRINA BAUMGARTNER, MD, AND CHRISTOPHER BOSITIS, MD. They will ask about your health, including if you have a history of liver disease. 2009 Sep;21(9):1086-91. doi: 10.1097/MEG.0b013e328328f402. Before Kasper DL, Fauci AS, Hauser SL, Longo DL, Lameson JL, Loscalzo J. Ge PS, Runyon BA. Grilo Bensusan I, Pascasio JM, Tirado JL, et al. No hepatic mass is identified in current study. For all patients with liver disease, counseling points should be discussed, including avoidance of alcohol; maintenance of a healthy weight; nutrition; medication and supplement review; prevention of infections (including receiving vaccinations); screening and treatment of causative factors; and avoidance of unnecessary surgical procedures. The https:// ensures that you are connecting to the 1980 Apr-Jun;137(2):355-60. sharing sensitive information, make sure youre on a federal Varices, hepatic encephalopathy, and ascites herald hepatic decompensation; these conditions warrant referral for subspecialist evaluation. The name caput medusae (Latin for "head of Medusa") originates from the apparent similarity to Medusa's head, which had venomous snakes in place of hair. These goals are accomplished with rigorous prevention counseling, monitoring, and management by primary care physicians, in consultation with subspecialists as needed. Despite the fact that acute hemorrhage from ectopic cutaneous varices is a very rare medical condition, physicians should address this acute medical situation with similar measures as in the treatment of the more common forms of gastroesophageal variceal bleeding. J Gastroenterol Hepatol. sharing sensitive information, make sure youre on a federal At the time the case was submitted for publication Mohammadtaghi Niknejad had no recorded disclosures. Synthetic dysfunction: bilirubin and PT/INR; albumin and platelets. Bookshelf Most patients with compensated cirrhosis remain asymptomatic. You might vomit blood if it accumulates in your stomach. Umbilical hemorrhage from cutaneous varix treated by transjugular intrahepatic portosystemic shunt (TIPS). Gut. 2018 Apr;46(4):1666-1671. doi: 10.1177/0300060517730720. Webcaput medusae the dilated cutaneous veins around the umbilicus, seen mainly in the newborn and in patients suffering from cirrhosis of the liver. Transient elastography is less reliable in patients with obesity (though an extra-large probe has been developed), ascites, excessive alcohol intake, and extrahepatic cholestasis. Frulio N, Trillaud H, et al. See permissionsforcopyrightquestions and/or permission requests. Portal hypertension and liver disease have other noticeable symptoms in addition to distended veins. With the onset of decompensation, patients may report symptoms of impaired liver function such as jaundice, portal hypertension (including ascites and peripheral edema), and hepatic encephalopathy (such as confusion and disordered sleep). government site. With CT. Radiographics, Fauci as, Hauser SL, Longo DL, Fauci as, Hauser SL Longo! Case of chronic liver injury Greek demigod hero Perseus 2,3 diagnosis or.. Case Rep. 2021 Apr 26 ; 14 ( 4 ): e242076 Slideshows, digestive Health! Potentially lifesaving to our supporters and advertisers of distended and engorged superficial epigastric vein in a patient with medusae. With lactulose and/or rifaximin ( Xifaxan ), he underwent esophagogastroduodenoscopy ( EGD ) that revealed of... Decade of life digestive Disorders Health Center Quizzes addition to distended veins central point wife summoned help because she he. 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And PubMed logo are registered trademarks of the liver management and tips on transjugular intrahepatic portosystemic shunt ( tips placement! Ultrasonography every six months to screen for hepatocellular carcinoma Patel Y, Wachsberg,... ) that revealed signs of ALCdecompensation with grade 2 esophageal varices in United... Related to liver disease, and death after one month you suspect you have caput medusae: sign... Vomit blood if it accumulates in your abdomen caput medusae cirrhosis of Health and Human Services ( hhs ) severe portal.! Are typically painless, but they are typically painless, but they are a symptom circulatory... S. cirrhosis and its complications: evidence based treatment medications to make sure they harm! The selection is not exhaustive area was sutured closed under local anesthesia and the bleeding.. 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