Thread by @ptfaddenMD

(1/8) #PhysicalExam #tweetorial
60 y/o hx of seizures & cirrhosis presenting after seizure & found to have distended abdominal wall veins. What is the cause? @VCU_IMRes @bedsidemedicine @StanfordMed25 @NateWarnerMD @AndreMansoor @PresRCPEdin (Consent was obtained per protocol)

(2/8) Bonus: what are the physical exam clues of cirrhosis? Any present here? @liverprof @scall1200 @rvawellmd @cderekleiner @michellebr00ks @medrants @CPSolvers @rabihmgeha @DxRxEdu @eozdalga @jackpenner @cjchiu @thecurbsiders @PaulNWilliamz @mia_bahagry

(3/8) Pay Attention to the direction of Venous Flow -> may suggest site of venous obstruction

JAMA Rational Clinical Examination outlines the technique - venous flow is the direction of most rapid refilling. @JAMAInternalMed @ehlJAMA @DavidLSimel #rationalclinicalexam

(4/8) Normal venous flow in the abdomen is typically Cephalad (towards the head) above the navel and Caudad (towards the feet) below the navel. For practical use: the maneuver should be performed both above and below the umbilicus.

(5/8) The most common cause of abdominal vein distention is obstruction of portal venous drainage (ex. portal hypertension). This can lead to Caput Medusae pic cred @NEJM

(6/8) Portal HTN- flow is always AWAY from the umbilicus 2/2 development of the portosystemic collaterals

SVC & IVC obstructions can also lead abdominal vein distention!

IVC obstruction - flow will be cephalad (towards SVC)
SVC obstruction - flow will be caudad (towards IVC)

(7/8) Though this pt does have cirrhosis, venous flow was dominantly caudad not typical for portal hypertension suggesting a possible SVC obstruction. CT imaging showed chronic stenosis of his SVC and additional lumbar & paraseophageal collaterals #physicalexamwin pic cred @NEJM

(8/8) Bonus: Patient has gynecomastia which was attributed to his advanced liver disease #lookunderthesheats

Special thanks to @DrJaredDyer @AudreyBJernigan for help with this #tweetorial