Caput medusae.

A 43 year old female was admitted in the medicine ward of Indira Gandhi Medical College Shimla, Himachal Pradesh, India, in December, 2013. She presented with painless enlarged veins on her abdomen for three months. Examination revealed grossly dilated, snake like tortuous veins on the anterior abdominal wall around umbilicus with direction of blood flow away from umbilicus. Based on examination the condition was diagnosed as caput medusae (Fig. A). Patient was found to have compensated cirrhosis due to chronic hepatitis B infection and had grade 3 oesophageal varices. An abdominal computed tomographic scan showed recanalized umbilical vein with collaterals extending to the abdominal wall (Fig.B). Oesophageal varices were managed by endoscopic variceal ligation (EVL). Patient was started on tenofovir 300 mg once a day. Patient was lost in follow up.

Fig. (A)

Large caput medusae over anterior abdomen wall. (B). Axial computed tomography (CT) abdomen showing subcutaneous collateral veins on the anterior abdominal wall communicating with umbilical vein opacified by radiocontrast (arrow). Also seen is enlarged spleen on left side.

Caput medusae is one of the cardinal features of portal hypertension. The appearance is due to cutanous portosystemic collateral formation between distended and engorged paraumbilical veins that radiate from the umbilicus across the abdomen to join systemic veins. Blood from the portal venous system is shunted through the umbilical veins into the abdominal wall veins, which manifest as the caput medusae. No specific treatment is required for this condition. It is rarely encountered in clinical practice nowadays due to earlier diagnosis and treatment of portal hypertension.