Spider angioma
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]
Overview
Historical Perspective
- [Disease name] was first discovered by [scientist name], a [nationality + occupation], in [year] during/following [event].
- In [year], [gene] mutations were first identified in the pathogenesis of [disease name].
- In [year], the first [discovery] was developed by [scientist] to treat/diagnose [disease name].
Classification
- Spider angioma may be classified into two groups:
- Benign solitary vascular malformation without any underlying conditions
- Multiple vascular malformations secondary to liver cirrhosis or hormonal imbalances.
- Classification based on videodermoscopy[1]:
- Network pattern
- Looping pattern
- Star pattern
Pathophysiology
- The pathogenesis of [disease name] is characterized by [feature1], [feature2], and [feature3].
- The [gene name] gene/Mutation in [gene name] has been associated with the development of [disease name], involving the [molecular pathway] pathway.
- On gross pathology, [feature1], [feature2], and [feature3] are characteristic findings of [disease name].
- On microscopic histopathological analysis, [feature1], [feature2], and [feature3] are characteristic findings of [disease name].
Causes
- Common causes of spider angioma include liver cirrhosis, hyperestrogenism, and thyrotoxicosis.
Differentiating spider angioma from other Diseases
- Spider angioma must be differentiated from other diseases that present with similar presentation such as:
- Angioma Serpiginosum
- Basal Cell Carcinoma
- Cherry Hemangioma
- Insect Bites
- Unilateral Nevoid Telangiectasia
Epidemiology and Demographics
- The prevalence of spider angioma is approximately 10,000-15,000 per 100,000 individuals in healthy adults and young children worldwide[2].
- According to a study, in children without liver involvement, 38% had at least one lesion. 8 of 10 children with cirrhosis had at least one lesion, only 4 of 34 children with chronic liver disease had five or more spiders present. There was an increasing trend with the age[3].
- A study reported around 22% prevalence in normal male children and 30% in normal female children[4].
- About 33% of the patients with advanced liver cirrhosis have spider angioma[5].
- A study of 60 pregnant women reported the presence of spider angioma in 32 of them[6].
Age
- The mean age was 39.5 years (range: 10–76 years)[1].
- Spider angioma is more common in women of childbearing age.
Gender
- There is no documented study showing gender predilection for Spider Angioma in otherwise healthy population.
- However there is an increased incidence in pregnant women, which is attributed to hyperestrogenic states.
Race
- There is no racial predilection for Spider Angiomas, but are more visibile in light skinned people.
Risk Factors
- Common risk factors in the development of spider angioma are those causing hyperestrogenic state (pregnancy, oral contraceptive pills) and liver cirrhosis (Alcohol, Viral hepatitis).
- Higher number of angiomas are seen in patients with Hereditary Hemorraghic Telangectasia[7]
Natural History, Complications and Prognosis
- The majority of healthy children and adults with spider angioma remain asymptomatic.
- Common complications of cutaneous spider angioma include bleeding secondary to manipulation.
- There could be relapsing gastrointestinal bleeding in those with internal lesion[8].
- Prognosis is generally excellent in those with resolution of underlying etiology.
- Physiological spider angiomas in younger adults usually increase till puberty and then disappear as the age advances[4].
- In women developing lesion during pregnancy may resolve post pregnancy.
- In women who take oral contraceptives and present with lesions, they may resolve after the patient discontinues the hormonal preparations.
Diagnosis
Diagnostic Criteria
- There is no diagnostic criteria for Spider angioma.
History and Symptoms
- Spider angioma, when not extensive, can be benign.
- When present extensively it could be due to an underlying cause.
- Alcoholism and higher bilirubin levels were proven to have correlation for development of Spider angiomas[5].
- Hyperestrogenic states like pregnancy, oral contraceptive pills etc could be the underlying cause in young females with no hepatic etiology[9].
Physical Examination
- Patients with benign spider angioma usually appear normal.
- Those secondary to underlying cause may have additional symptoms pertaining to the disease.
- A spider angioma has 3 features: a body with small bright red lesions (1mm -10mm) with a central red spot, a leg with radiating thin-walled vessels and surrounding erythema[10].
- Unusually large presentations with visible pulsatile blood flow have also been reported[11][12].
- The blood pressure measures 50 to 70 mm Hg in these small arterioles[10].
- Spider angiomas are usually present on face, chest and arms in the distribution of Superior Vena Cava. But unusual presentations with Palpebra[9], Pluera and subpleura[13], Esophaghus [14],and Gastrointestinal tracts [15] have been reported.
Diascopy
- Diascopy is the procedure of applying pressure using glass slide or paper on the lesion to asses for blanchability.
- Pallor upon application of pressure, followed by refilling upon relieving the pressure is characteristic of spider angioma.
Laboratory Findings
- Laboratory work up for hepatic etiology (Liver function tests, Viral markers), pregnancy (urine pregnancy test), hyperestrogenic etiology (Estrogen and FSH levels) and thyrotoxicosis (T3,T4, and TSH)[2] should be done.
Electrocardiogram
- There are no ECG findings associated with Spider angiomas.
X-ray
- There are no x-ray findings associated with Spider angiomas.
Echocardiography or Ultrasound
- There are no echocardiography/ultrasound findings associated with Spider angiomas as such.
- Ultrasound has a high positive predictive value in identifying the underlying liver cirrhosis[16].
- Ultrasound may be useful in identifying underlying ovarian tumors[17].
CT scan
- There are no CT scan findings associated with Spider angiomas.
- CT scan is the most sensitive imaging modality for identifying the underlying liver cirrhosis[18].
- Ct scan can reveal underlying ovarian tumors[19].
MRI
- There are no MRI findings associated with Spider angiomas.
Other Imaging Findings
- There are no other imaging findings associated with Spider angiomas.
Other Diagnostic Studies
- Biopsy may be helpful in the diagnosis of Spider angioma when the presentation isn't classical. Findings diagnostic of spider angioma include Cutaneous arterial net, Central spider arteriole, Subepidermal ampulla , Star shaped arrangement of efferent spider vessels, and Capillaries[20].
Grading
Medical Therapy
Treatment
Medical Therapy
- There is no treatment for [disease name]; the mainstay of therapy is supportive care.
- The mainstay of therapy for [disease name] is [medical therapy 1] and [medical therapy 2].
- [Medical therapy 1] acts by [mechanism of action 1].
- Response to [medical therapy 1] can be monitored with [test/physical finding/imaging] every [frequency/duration].
Surgery
- Surgery is the mainstay of therapy for [disease name].
- [Surgical procedure] in conjunction with [chemotherapy/radiation] is the most common approach to the treatment of [disease name].
- [Surgical procedure] can only be performed for patients with [disease stage] [disease name].
Prevention
- There are no primary preventive measures available for [disease name].
- Effective measures for the primary prevention of [disease name] include [measure1], [measure2], and [measure3].
- Once diagnosed and successfully treated, patients with [disease name] are followed-up every [duration]. Follow-up testing includes [test 1], [test 2], and [test 3].
References
- ↑ 1.0 1.1 Alegre-Sánchez A, Bernárdez C, Fonda-Pascual P, Moreno-Arrones OM, López-Gutiérrez JC, Jaén-Olasolo P; et al. (2018). "Videodermoscopy and doppler-ultrasound in spider naevi: towards a new classification?". J Eur Acad Dermatol Venereol. 32 (1): 156–159. doi:10.1111/jdv.14602. PMID 28960458.
- ↑ 2.0 2.1 Khasnis A, Gokula RM (2002). "Spider nevus". J Postgrad Med. 48 (4): 307–9. PMID 12571391.
- ↑ Finn SM, Rowland M, Lawlor F, Kinsella W, Chan L, Byrne O; et al. (2006). "The significance of cutaneous spider naevi in children". Arch Dis Child. 91 (7): 604–5. doi:10.1136/adc.2005.086512. PMC 2082833. PMID 16595646.
- ↑ 4.0 4.1 WENZL JE, BURGERT EO (1964). "THE SPIDER NEVUS IN INFANCY AND CHILDHOOD". Pediatrics. 33: 227–32. PMID 14117378.
- ↑ 5.0 5.1 Li CP, Lee FY, Hwang SJ, Chang FY, Lin HC, Lu RH; et al. (1999). "Spider angiomas in patients with liver cirrhosis: role of alcoholism and impaired liver function". Scand J Gastroenterol. 34 (5): 520–3. doi:10.1080/003655299750026272. PMID 10423070.
- ↑ Estève E, Saudeau L, Pierre F, Barruet K, Vaillant L, Lorette G (1994). "[Physiological cutaneous signs in normal pregnancy: a study of 60 pregnant women]". Ann Dermatol Venereol. 121 (3): 227–31. PMID 7832550.
- ↑ Sadick H, Sadick M, Götte K, Naim R, Riedel F, Bran G; et al. (2006). "Hereditary hemorrhagic telangiectasia: an update on clinical manifestations and diagnostic measures". Wien Klin Wochenschr. 118 (3–4): 72–80. doi:10.1007/s00508-006-0561-x. PMID 16703249.
- ↑ Katsanos KH, Sigounas DE, Christodoulou DK, Tsianos EV (2012). "Bleeding colonic spider angioma". Ann Gastroenterol. 25 (3): 259. PMC 3959367. PMID 24714144.
- ↑ 9.0 9.1 Yalcin K, Ekin N, Atay A (2013). "Unusual presentations of spider angiomas". Liver Int. 33 (3): 487. doi:10.1111/liv.12009. PMID 23121469.
- ↑ 10.0 10.1 "StatPearls". 2021. PMID 29939595.
- ↑ Hane H, Yokota K, Kono M, Muro Y, Akiyama M (2014). "Extraordinarily large, giant spider angioma in an alcoholic cirrhotic patient". Int J Dermatol. 53 (2): e119–21. doi:10.1111/j.1365-4632.2012.05548.x. PMID 23451770.
- ↑ Sharma A, Sharma V (2014). "Giant spider angiomas". Oxf Med Case Reports. 2014 (3): 55. doi:10.1093/omcr/omu023. PMC 4370005. PMID 25988027.
- ↑ Daimaru N, Okamura T, Nagano H, Shigematsu N, Yasunaga C, Sueishi K (1990). "[Hypoxemia of liver cirrhosis--an autopsy case study]". Nihon Kyobu Shikkan Gakkai Zasshi. 28 (11): 1504–10. PMID 2290237.
- ↑ Nur FA, Clemente C, Serino G, Salerno F, Spina L, Vecchi M (2010). "Atypical esophageal vascular lesions observed in liver cirrhosis". Dis Esophagus. 23 (1): E9–E11. doi:10.1111/j.1442-2050.2009.01018.x. PMID 19863641.
- ↑ Madhira, M.S. and M. Tobi. Isolated gastrointestinal spider nevi: potential clinical significance. Am J Gastroenterol, 2000; 95(10): 3009-3010
- ↑ Viganò M, Visentin S, Aghemo A, Rumi MG, Ronchi G (2005). "US features of liver surface nodularity as a predictor of severe fibrosis in chronic hepatitis C." Radiology. 234 (2): 641, author reply 641. doi:10.1148/radiol.2342041267. PMID 15671013.
- ↑ Twickler DM, Moschos E (2010). "Ultrasound and assessment of ovarian cancer risk". AJR Am J Roentgenol. 194 (2): 322–9. doi:10.2214/AJR.09.3562. PMID 20093591.
- ↑ Kudo M, Zheng RQ, Kim SR, Okabe Y, Osaki Y, Iijima H; et al. (2008). "Diagnostic accuracy of imaging for liver cirrhosis compared to histologically proven liver cirrhosis. A multicenter collaborative study". Intervirology. 51 Suppl 1: 17–26. doi:10.1159/000122595. PMID 18544944.
- ↑ Jung SE, Lee JM, Rha SE, Byun JY, Jung JI, Hahn ST (2002). "CT and MR imaging of ovarian tumors with emphasis on differential diagnosis". Radiographics. 22 (6): 1305–25. doi:10.1148/rg.226025033. PMID 12432104.
- ↑ Graham-Brown RAC and Sarkany I. The hepatobiliary system and the skin. In: Freedberg IM, Eisen AZ, Wolff K, Austen KF, Goldsmith LA, Katz SI, et al. Editors. Fitzpatrick’s Dermatology in General Medicine. McGraw Hill 1999. Pp1972