The Liver

Abstract

Bulging flanks together with a round symmetrical contour of the abdomen indicate the presence of ascites (Fig. 9.1). Ankle or lower leg oedema is present in the majority of patients with ascites of hepatic origin. Eversion of the umbilicus is a sign of large-volume, chronic ascites. Prominent veins draining centrifugally from the periumbilical area over the abdomen (caput medusae) indicate portosystemic collaterals in patients with portal hypertension (Fig. 9.2). Palpation of the veins often reveals a thrill or a continuous venous hum on auscultation. A similar picture with collateral veins of the lateral abdomen can be observed in patients with the inferior vena cava syndrome. The two conditions can be differentiated by the direction of flow in the veins (centrifugal vs. cephalad) (Box 1).

Clinical Practice

Box 1 Abdominal Veins: Direction of Flow and Interpretation

Direction of flow	Interpretation
Superior	Inferior vena cava obstruction
Inferior	Superior vena cava obstruction
Radiating from the umbilicus (centrifugal)	Portal hypertension

William Harvey’s method of checking the direction of flow in veins of the abdominal wall: In order to assess the direction of low, the examiner presses on one abdominal vein with two index fingers adjacent to each other. Then pull the fingers apart. Lift one finger and note whether the vein fills.