A 55-year-old man comes to the office reporting "a swollen belly and puffy feet" that began several months ago. He has not seen a physician for several years but says that he was previously diagnosed with depression. The patient takes no medications. He currently lives alone and is unemployed. He admits to drinking 6-12 beers a night, depending on what he can afford. He has a remote history of cigarette smoking. Physical examination reveals bilateral gynecomastia, spider angiomas on the chest, Dupuytren contracture of both hands, and palmar erythema. Dilated periumbilical veins are also visible. Percussion of the abdomen demonstrates shifting dullness. Splenomegaly is present. There is no evidence of asterixis. There is pitting edema of the lower extremities. Laboratory studies reveal increased prothrombin time and thrombocytopenia. Which of the following findings has the same pathogenesis as spider angiomas?

Question

A 55-year-old man comes to the office reporting "a swollen belly and puffy feet" that began several months ago.  He has not seen a physician for several years but says that he was previously diagnosed with depression.  The patient takes no medications.  He currently lives alone and is unemployed.  He admits to drinking 6-12 beers a night, depending on what he can afford.  He has a remote history of cigarette smoking.  Physical examination reveals bilateral gynecomastia, spider angiomas on the chest, Dupuytren contracture of both hands, and palmar erythema.  Dilated periumbilical veins are also visible.  Percussion of the abdomen demonstrates shifting dullness.  Splenomegaly is present.  There is no evidence of asterixis.  There is pitting edema of the lower extremities.  Laboratory studies reveal increased prothrombin time and thrombocytopenia.  Which of the following findings has the same pathogenesis as spider angiomas?

Quizplus · Accepted Answer

11ec25c8_d3e0_9429_bc81_61b02d200924_MD0003_00 This patient has numerous findings suggestive of alcoholic cirrhosis of the liver. Cirrhosis of any type leads to progressive loss of liver function, which can be divided into 3 categories: synthetic (production of clotting factors, cholesterol, and proteins); metabolic (metabolism of drugs and corticosteroids, including detoxification); and excretory (bile excretion). In patients with cirrhosis, spider angioma and palmar erythema both arise from hyperestrinism due to impaired hepatic metabolism of circulating estrogens, a process that begins in the cytochrome P450 system. Circulating estrogens affect vascular wall dilation. Spider angioma consists of a central, dilated arteriole surrounded by smaller radiating vessels. Palmar erythema is a result of increased normal speckling of the palm due to increased vasodilation, especially at the thenar and hypothenar eminences. Other manifestations of hyperestrinism in patients with cirrhosis include gynecomastia, testicular atrophy, and decreased body hair in males. Spider angioma (Choices A and E) Caput medusae arise from the dilation of superficial veins on the abdominal wall due to portal hypertension (PH). PH results from increased resistance to portal flow at the sinusoids and leads to increased pressure at the portosystemic collateral veins in the anterior abdomen, rectum, and distal esophagus. This then predisposes to esophageal varices, rectal varices, and caput medusae. Similarly, PH causes enlargement of the spleen (which drains into the portal vein via the splenic vein) due to vascular congestion of the red pulp. Caput medusae (Choice B) Dupuytren contracture occurs when the palmar fascia thickens and shortens, deforming the hand. It is usually most notable initially in the fourth and fifth digits and occurs due to fibroblast proliferation and collagen deposition, which are likely worsened by oxidative stress from increased free radical production. Dupuytren contracture (Choice D) The liver is the primary site of protein synthesis, and the cirrhotic liver typically produces insufficient amounts of proteins, including albumin. Hypoalbuminemia leads to both a decrease in the intravascular oncotic pressure and fluid shifts to the extravascular space, predisposing to edema of the lower extremities. Educational objective: Hyperestrinism in cirrhosis leads to gynecomastia, testicular atrophy, decreased body hair, spider angiomas, and palmar erythema. References: Cirrhosis and chronic liver failure: part I. Diagnosis and evaluation. (http://www.ncbi.nlm.nih.gov/pubmed/16970019) Cirrhosis and chronic liver failure: part II. Complications and treatment. (http://www.ncbi.nlm.nih.gov/pubmed/16970020) Images in clinical medicine. Spider angioma. (http://www.ncbi.nlm.nih.gov/pubmed/22356347)

A 55-Year-Old Man Comes to the Office Reporting "A Swollen