Spider nevi and chronic liver disease

Sir,

We read with interest the article ′Spider nevi: A presenting feature of chronic liver disease.′ The authors state that spider nevi predated the onset of liver disease. ^[1] This may not be entirely correct as the patient was not completely investigated for liver disease at initial presentation. Patients with liver dysfunction can be entirely symptom free and even the entire set of liver function tests, on occasion, may fail to detect an underlying hepatic disorder. In these cases only imaging or/and liver biopsy may identify liver disease. It is important that all patients with half a dozen or more spider angiomas are investigated to rule out liver disease since these are described as markers of portal hypertension especially if found in superior venacaval distribution. ^[2]

Though effort has been made to rule out viral, alcoholism, non-alcoholic steatohepatitis, autoimmune hepatitis and a1 antitrypsin deficiency as cause of cirrhosis, it may not be correct to label the patient as a case of cryptogenic cirrhosis. Short of biopsy, the indirect and direct bilirubin, serum aspartate transaminase and albumin levels could have given more information about cause of liver dysfunction. In such cases where the aetiology is uncertain, certain specific investigations may help in identifying the cause. Patients of hemochromatosis with underlying liver dysfunction can be entirely asymptomatic and without any abnormal liver function tests. A serum iron profile would have clarified the issue. ^[3] Wilson′s disease usually presents in childhood or teenage years but can present as late as the fifth decade. Wilson′s disease can present as cirrhosis. Slit-lamp examination for Kayser-Fleischer ring, as also serum ceruloplasmin levels and 24-h urinary copper (Wilson) are helpful in identifying most cases. ^[4] All possible efforts should be made to identify the etiology of chronic liver disease as this has implications on management and prognosis.