Spider angiomata

Q: 44 years old male with known end-stage cirrhosis is admitted with variceal hemоrrhаge. Physical exam shows all stigmata of liver cirrhosis, including skin lesions, which appear to be spider angiomata. What's the best way to confirm the diagnosis of spider angiomata? 

Answer: Press the lesion with a glass slide. 

Spider angiomata, also known as spider telangiectasia or spider nevi, is one of the well-known stigmata signs of end-stage hepatic cirrhosis. It is a vascular lesion with a central arteriole surrounded by many smaller vessels. When compressed with a glass slide, the body of the lesion, i.e., the central arteriole, can be seen as pulsating. This is because the blood fills the central arteriole first before traveling to the peripheral tips of each "leg" after blanching. Its clinical importance lies in the number and size of spider angiomata correlated with the severity of liver disease. Patients with numerous large spider angiomata may be at increased risk for variceal bleeding.

 It is believed that alterations in sex hormone metabolism with an increase in the estradiol-to-free tеѕtοѕterοne ratio. Although conventionally, they are considered to be only part of cirrhosis but can be seen in pregnancy and severe mаlnսtritiоn due to the same alterations in sex hormone metabolism. They are usually seen on the trunk, face, and upper limbs. 

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 References: 

 1. Pirovino M, Linder R, Boss C, et al. Cutaneous spider nevi in liver cirrhosis: capillary microscopical and hormonal investigations. Klin Wochenschr 1988; 66:298. 

 2. Zaman A, Hapke R, Flora K, et al. Factors predicting the presence of esophageal or gastric varices in patients with advanced liver disease. Am J Gastroenterol 1999; 94:3292. 

 3. Foutch PG, Sullivan JA, Gaines JA, Sanowski RA. Cutaneous vascular spiders in cirrhotic patients: correlation with hemorrhage from esophageal varices. Am J Gastroenterol 1988; 83:723.