A 57-year-old female with significant alcohol exposure, hepatitis C and liver cirrhosis was admitted for management of dehydration and anaemia. On examination she had spider angiomas, a palpable firm left lobe of the liver and clubbing. Dilated tortuous superficial epigastric veins (caput medusae, figure 1) were noted above the umbilicus radiating from a central large venous varix like snakes emerging from Medusa's head. So far, none of the onlookers have turned into stone!

• Download figure
• Open in new tab
• Download powerpoint

Figure 1

Dilated superficial (superior and inferior) epigastric veins radiating from a central large venous varix.

A review of the patient's recent CT of the abdomen revealed a large recanalised paraumbilical vein (figure 2) originating from the left side of the portal vein. It coursed through the falciform ligament towards the epigastric abdominal wall to empty into a large varix (figure 2). Superior and inferior epigastric veins from the varix then drained into the axillary and femoral veins, respectively, forming porto-systemic circulation.

• Download figure
• Open in new tab
• Download powerpoint

Figure 2

CT of the abdomen revealing a large canalised paraumbilical vein (arrow) emptying into a large varix (arrowhead).