Caput medusae in alcoholic liver disease

Caput medusae is the appearance of distended and engorged superficial epigastric veins, which are seen radiating from the umbilicus across the abdomen.

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Case report: A 53-year-old man, with history of alcohol consumption of 60 gm/day for 20 years, presented with swelling of the legs, abdominal distension, and a collapsible localized swelling over the abdomen since 3 months. He denied any past history of jaundice and had no symptoms of encephalopathy or coagulopathy. Examination revealed a normotensive individual with pallor, pedal edema, spider nevi, parotidomegaly, and palmar erythema. Abdominal examination revealed hepatomegaly, ascites, and a large caput medusae with collaterals. Auscultation over the caput medusae revealed a Cruveilhier-Baumgarten murmur. Blood flow in the collaterals was not indicative of inferior vena cava obstruction. His serum bilirubin was 23.9 μmol/L, alanine aminotransferase 34 U/L, aspartate aminotransferase 45 U/L, alkaline phosphatase 98 U/L, serum proteins 54 g/L, serum albumin 32 g/L, and serum globulin 22 g/L. Ascitic fluid analysis revealed straw-colored fluid with proteins of 11 g/L and white blood cell count of 80/cu mm, with lymphocytes predominating. His SAAG (serum-ascites albumin gradient ) was 2.1, which was suggestive of portal hypertension.

Upper gastrointestinal endoscopy revealed grade 3 esophageal varices, with no signs of recent hemorrhage. Sonography of the abdomen revealed enlarged portosystemic collaterals, with a recanalized umbilical vein. Viral marker screens to look for coexisting chronic hepatitis were negative. The patient was diagnosed as a case of alcoholic liver disease leading to cirrhosis with decompensation (in form of ascites and portal hypertension). Ascites was managed with salt restriction, diuretics, and propranolol; endoscopic ligation was done for the esophageal varices. The caput medusae was left alone as no specific treatment was deemed necessary for the same. During the last 8 months of follow-up, the edema and ascites have decreased considerably with medical management and there has been no evidence of encephalopathy, coagulopathy, or gastrointestinal bleeding.

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