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Logo of bmjcrInstructions for authorsCurrent ToCBMJ Case Reports
BMJ Case Rep. 2010; 2010: bcr0320102795.
Published online Dec 6, 2010. doi:  10.1136/bcr.03.2010.2795
PMCID: PMC3028153
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Caput medusae
Nishith K Singh, Usman Cheema, and Ali Khalil
Department of Internal Medicine, Southern Illinois University School of Medicine, Springfield, Illinois, USA
Correspondence to Nishith K Singh, nishith.singh/at/
A 57-year-old female with significant alcohol exposure, hepatitis C and liver cirrhosis was admitted for management of dehydration and anaemia. On examination she had spider angiomas, a palpable firm left lobe of the liver and clubbing. Dilated tortuous superficial epigastric veins (caput medusae, figure 1) were noted above the umbilicus radiating from a central large venous varix like snakes emerging from Medusa's head. So far, none of the onlookers have turned into stone!
Figure 1
Figure 1
Dilated superficial (superior and inferior) epigastric veins radiating from a central large venous varix.
A review of the patient's recent CT of the abdomen revealed a large recanalised paraumbilical vein (figure 2) originating from the left side of the portal vein. It coursed through the falciform ligament towards the epigastric abdominal wall to empty into a large varix (figure 2). Superior and inferior epigastric veins from the varix then drained into the axillary and femoral veins, respectively, forming porto-systemic circulation.
Figure 2
Figure 2
CT of the abdomen revealing a large canalised paraumbilical vein (arrow) emptying into a large varix (arrowhead).
Competing interests None.
Patient consent Obtained.
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