Cirrhosis: The Daily PANCE Blueprint

Cirrhosis: The Daily PANCE Blueprint

Which of the following describes the appearance of distended and engorged superficial epigastric veins, which are seen radiating from the umbilicus across the abdomen seen in patients with cirrhosis?

A. caput medusae
B. spider angiomata
C. palmar erythema
D. scleral icterus

Answer and topic summary

The answer is A. caput medusae

Caput medusae, also known as palm tree sign, is the appearance of distended and engorged superficial epigastric veins, which are seen radiating from the umbilicus across the abdomen.

  • Spider angioma is an abnormal collection of blood vessels near the surface of the skin.
  • Palmar erythema is a reddening of the skin on the palmar aspect of the hands, usually over the hypothenar eminence. It may also involve the thenar eminence and fingers. It can also be found on the soles of the feet when it is termed plantar erythema.
  • The yellowing of the “white of the eye” is thus more properly termed conjunctival icterus. The term “icterus” itself is sometimes incorrectly used to refer to jaundice that is noted in the sclera of the eyes, however, its more common and more correct meaning is entirely synonymous with jaundice.
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Pearls

Cirrhosis is a chronic liver disease that evolves slowly, has a prolonged course, and occurs as a result of excessive alcohol intake (21%), nonalcoholic fatty liver disease (NFLD – 10%), or chronic hepatitis C (26%). As a result of these disorders, cirrhosis stems from degeneration and destruction of liver cells

  • Patients with cirrhosis are at risk of developing several major complications, such as portal hypertension. This can lead to ascites and esophageal varices.
  • Other complications include decreased liver function, which manifests as coagulation defects
  • Amonia produced in the GI tract is usually metabolized by the liver
  • Encephalopathy can occur from ammonia buildup, and hepatorenal syndrome, leading to renal failure

Diagnosis

  • Typically AST > ALT
  • ALP and ↑ GGT
  • Anemia from hemolysis, folate deficiency, and splenomegaly
  • Decreased platelet count from portal hypertension with splenomegaly
  • Decreased bilirubin conjugation by the liver ⇒ ↑ unconjugated bilirubin ⇒ jaundice
  • Decreased albumin production by the liver ⇒ hypoalbuminemia
  • Decreased clotting factor production by the liver ⇒ Prolonged prothrombin (PT), international normalized ratio (INR), partial thromboplastin time (PTT)
  • Ultrasound: helpful to determine the liver size and evaluate for hepatocellular carcinoma
  • Liver biopsy is the GOLD STANDARD and is often required for definitive diagnosis
  • All patients with cirrhosis should have an EGD ⇒ exclude esophageal varices

Treatment

Generally scarring from cirrhosis is irreversible ⇒ prevent further damage by identifying and treating the underlying cause

  • Stop alcohol
  • Antiviral treatment for Hepatitis C
  • Corticosteroids for autoimmune hepatitis
  • Chelation therapy (e.g. penicillamine) for Wilson disease
  • Diuretics, antibiotics, laxatives, enemas, thiamine, steroids, acetylcysteine, pentoxifylline for decompensation
  • Nonselective beta-blockers (nadolol and propranolol) for primary prophylaxis against variceal hemorrhage or esophageal variceal ligation (EVL)
  • For advanced cirrhosis ⇒ liver transplant may be necessary
  • Encephalopathy ⇒ lactulose + neomycin
  • Ascites ⇒ sodium restriction, paracentesis
  • Pruritus: ⇒ cholestyramine

Smarty PANCE Content Blueprint Review:

Covered under ⇒ PANCE Blueprint GI and Nutrition (9%)Hepatic Disorders (PEARLS)