A 56-year-old man was seen in the emergency department complaining of swelling of both arms. On questioning, he said that he first noticed that his hands were swollen 3 weeks earlier. He admitted being a heavy smoker and had on several occasions coughed up bloodstained sputum. On examination, his face looked puffy,especially around the eyes. Pitting edema was present in both the upper limbs, the face, and the neck. With the patient in the recumbent position, numerous dilated superficial veins were seen over the chest wall and abdomen. Later a chest radiograph revealed a large opacity in the upper lobe of the right lung. A diagnosis of advanced bronchogenic carcinoma of the right upper lobe was made. Can you explain the presence of edema in both the upper limbs, the face, and the neck? What is the cause of the dilated superficial veins of the chest and abdominal walls? Is there normally communication between the main veins draining the upper part of the body and those draining the lower half of the body?

Question

Quizplus · Accepted Answer

The Answer is The swelling of both upper extremities and the head and neck, caused by edema, and the engorgement of the superficial veins of the chest and abdominal walls clearly indicate the presence of a superior vena caval obstruction. This obstruction was caused by the expanding metastases in the mediastinal lymph nodes secondary to the bronchogenic carcinoma. The dilated superficial veins included the lateral thoracic vein, a tributary of the axillary vein; lumbar veins, tributaries of the inferior vena cava; and the superficial epigastric vein, a tributary of the great saphenous vein of the leg
that drains into the femoral vein. These venous channels provide an alternative pathway in superior vena caval obstruction, permitting superior vena caval blood to return to the heart via the inferior vena cava. The superior vena cava normally communicates with the inferior vena cava through the azygos veins. However, in this case the tumor was pressing on the superior vena
cava proximal to the entrance of the azygos vein

A 56-Year-Old Man Was Seen in the Emergency Department Complaining