umbilicus. This is caused by backflow through the collateral veins within the falciform ligament, and this pattern is called caput medusae.

If the superficial veins are distended, evaluate the direction of drainage by the following technique: Place the tips of your index fingers on a vein that is oriented cephalad-caudad, not transverse, and compress it. Using continuous pressure, slide your index fingers apart for about 3 to 4 inches (7.5 to 10 cm). Remove one finger and observe the refilling in the direction of flow. Repeat this procedure, but this time remove your other finger and observe the direction of flow. Figure 17-14 shows the abdomen of a patient with intrahepatic portal hypertension. Notice the engorged paraumbilical veins; the flow was away from the umbilicus toward the caval system.

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