Spider naevi

Figure 4.2 Spider naevi. Reproduced with permission from Fitzpatrick TB (1997), Color Atlas and Synopsis of Clinical Dermatology, 3rd edn. McGrow Hill.

Portal hypertension with varices, two previous bleeds Encephalopathy grade II Spider naevi... 

Patients with liver cirrhosis often show typical facial skin stigmata the colour is a pallid yellowish grey, mostly with patchy pigmentation due to the greater deposition of melanin. Spider naevi and reticular telangiectases are found. The skin frequently appears shrivelled, wrinkled and prematurely aged. 

The term spider naevus (Latin naevus araneus) is also known as liver star, liver spider, vascular spider or spider naevi. (17, 20, 25, 30)... 

It would appear that the spider naevi occur as segmental reflexes, depending on visceral affections. This would explain why they blossom and reoccur when the liver condition deteriorates, and fade when the liver condition improves. The occurrence and rapid appearance of fresh spiders can be considered as an unfavourable sign, such as is observed, for example, in serious virus hepatitis or in the development of primary liver cell carcinoma. 

Aetiopathogenesis As with spider naevi, the capillary dilatation causing palmar erythema is attributed to an increased oestrogen content of the blood, a rise in bile acids or endotoxins and an activation of vasodilating substances with more numerous arteriovenous shunts and a hypercirculatory syndrome. Portal hypertension is seen as an important codeterminant. The blossoming of spider naevi and palmar erythema is also observed in the phenomenon of haemodynamic-related resistance to diuretics. 

Incomplete spider naevi can develop within a palmar erythema they have no central artery. The combination of these two liver skin stigmata is frequently found in decompensated liver cirrhosis and in highly active chronic hepatitis. 

Apart from spider naevi, reticular telangiectases are frequently witnessed, particularly in alcoholic liver disease. They appear as tiny, bluish red vessels, in general symmetrically positioned on the cheeks, but also on the nose, forehead and neck. Those parts of the skin that are exposed to light are predominantly affected. The arterial and venous capillary loops are dilated. 

Liver-disease patients often display white spots on the skin, which are the size of a lentil (sometimes as large as 0.5-1.0 cm in diameter). They can be detected chiefly in the area of the arms, on the back and on the buttocks. Upon cooling of the skin, white spots appear or become more pronounced, so that a cold-related vasocontrac-tion is assumed to be the causative factor. In the predilection area of the spider naevi, the white spotting of the skin can be deemed a preliminary stage of liver star within the round white spot, a central red dot is formed, from which the typical spider naevus develops with a white areola. 

Whereas Dupuytren s contracture is only found in about 2% of the population, it is detectable in about 30% of all cirrhosis patients, mainly bilaterally. Men are affected in 90% of cases and thus far more often than women. The disease generally commences unilaterally. Men are frequently affected in their younger years, whereas in women, the disease commences later and takes a more rapid course. There is a greater tendency towards recurrence of the disease after surgery than after radiological treatment. In cirrhosis patients, contracture occurs predominantly in combination with palmar erythema. There also seems to be a correlation between contracture and spider naevi. (2, 4, 12, 23)... 

The clinical situation deteriorates rapidly febrile temperatures and leucocytosis as well as subicterus are observed there are also signs of encephalopathy. An arterial murmur can often be heard on auscultation, since the tumour is mainly supplied with blood from the hepatic artery. A sudden blossoming of vascular spider naevi is frequently seen with underlying cirrhosis. Virchow s lymphadenopathy may be present. (84) Fever and leucocytosis frequently occur in tumour necrosis. Clinical findings include ... 

The final steps are the write-up and publication. Your supervisor should guide you towards the most appropriate peer-reviewed journal for publication. Think about the impact factor (measure of the number of citations to recent articles) as a proxy marker of the journal s importance, but be realistic the Lancet probably won t give you a 10-page spread on spider naevi in people with OCD. 

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