Picture quiz: End of the bed
During a clinical placement on a medical ward, the specialist registrar challenges you to make “an end of the bed diagnosis.” The patient is a 49 year old man, a former smoker, who presented with severe dyspnoea and pitting oedema in the lower limbs. He has a history of recurrent deep venous thrombosis and pulmonary embolism. From the end of the bed you can see the patient is wearing a face mask providing high flow oxygen, his jugular venous pressure is markedly raised, and the appearance of his abdomen is grossly abnormal (figure below).
In cases of chronic venous obstruction, collateral vessels become engorged with blood trying to bypass the blockage. If these collateral veins are superficial then they become visible through the skin, as can be seen in this patient. The other well known example of this phenomenon is “caput medusea,” seen in portal hypertension and it may also